Quick Way to Write Coronary Artery Disease SOAP Notes for Healthcare Providers

Coronary Artery Disease SOAP Notes

It's the end of a long clinic day, and you've got five charts open on your screen.

Two chest pain follow-ups, one post-stent patient, and two stable angina patients who need medication adjustments.

You're trying to remember who had the abnormal stress test, who's compliant with their statins, and which patient needs that cardiology referral you promised.

Your documentation needs to be tight enough to justify ongoing cardiac care to insurance, but your brain is fried.

Sound familiar? If you've ever found yourself in these shoes, keep on reading.

We've all been here.

Quick Tip:

SOAP Notes Doctor is our product that transforms recordings, audios, and text into industry-standard SOAP notes.

You can let it listen to your patient encounters and do the work.

You can add, edit, review, and add more context later.

Head over to soapnotes.doctor now.

Let's dive in.

SOAP Notes: The Quick Story

Back in the day, cardiac documentation was all over the place.

One provider might scribble "chest pain - gave nitro" while another would write a dissertation about every risk factor since birth.

There was no consistency, no way to quickly scan a chart and understand the patient's cardiac status.

Then in the late 1960s, Dr. Lawrence Weed decided enough was enough and created the Problem-Oriented Medical Record with SOAP notes as the foundation.

His brilliant idea was simple: give everyone the same framework so any provider could pick up a chart and immediately understand what's happening.

Here's what Dr. Weed came up with:

• S (Subjective): What the patient tells you about their symptoms, chest pain, activity tolerance
• O (Objective): What you observe and measure - vitals, exam findings, EKG, labs
• A (Assessment): Your clinical judgment about their cardiac status and risk level
• P (Plan): Your treatment strategy and monitoring plan

This format became essential in cardiology because you need to document symptom patterns, risk stratification, medication optimization, and response to interventions - all in a way that justifies continued care and specialist involvement.

How to Write CAD SOAP Notes: My Recommended Approach

When I started working with cardiologists and primary care docs managing cardiac patients, I noticed a pattern.

They'd spend way too long trying to document every little detail about coronary disease.

Then I figured out the secret:

"Focus on what changes risk. Everything else is noise."

Document chest pain characteristics, functional status, medication adherence, and cardiac risk factors. That's your foundation. The rest is just filler.

I learned this from watching efficient cardiologists work, and I built soapnotes.doctor around it.

There are technically two ways you can approach CAD SOAP notes. You can write them manually, or you can use soapnotes.doctor.

Use soapnotes.doctor

I'll choose soapnotes.doctor every single time because it's consistent, captures all the risk stratification insurance wants, and most importantly, it's faster than manually typing complex cardiac documentation.

Here's how to streamline the whole process:

1. Head over to soapnotes.doctor to get started. Complete the onboarding process if you're new to the platform.

2. Click on the record button to either record the patient encounter or dictate your findings after the visit.

3. Wait 1-3 minutes.

4. Review and save.

One beauty of soapnotes.doctor is that it just gets cardiac documentation right. Not overly wordy, yet never misses the critical details that insurance companies scrutinize for cardiac patients. That's the sweet spot.

And if you need to make edits, you have the tailorr feature at your disposal. Edit, approve, add context, and copy straight to your EHR.

Write Manually

Maybe you're traditional, or maybe you just want full control over your documentation. Here's how to do it efficiently.

1. S - Subjective

This is where you capture the patient's cardiac symptoms and functional status.

This section should document what your patient tells you about chest pain, shortness of breath, and how their heart disease affects daily life.

Purpose: Document the patient's cardiac symptoms, exercise tolerance, and medication adherence.

What to include:

• Chest pain characteristics (onset, quality, duration, radiation, triggers, relieving factors)
• Dyspnea on exertion and exercise tolerance
• Associated symptoms (diaphoresis, nausea, palpitations)
• Medication compliance, especially antiplatelet agents and statins
• Recent cardiac events or interventions
• Risk factor management (smoking, diet, exercise)

Examples:

"Patient reports substernal chest pressure 5/10 occurring with walking more than two blocks, relieved with rest after 3-5 minutes. Denies chest pain at rest. Using sublingual nitroglycerin approximately twice weekly with good relief. Takes aspirin 81mg, atorvastatin 40mg, and metoprolol daily without missing doses. Quit smoking 6 months ago, walking 20 minutes daily. Denies orthopnea, PND, or lower extremity edema."

"Patient denies any chest pain or pressure since last visit 3 months ago. Able to climb two flights of stairs and walk dog 30 minutes daily without symptoms. Taking all cardiac medications as prescribed including dual antiplatelet therapy post-stent. Following cardiac diet, lost 8 pounds since stent placement. No nitroglycerin use in past month."

2. O - Objective

This is where you document what you observe, measure, and test.

The objective section is where you record vital signs, cardiac exam findings, and relevant test results.

Purpose: Document measurable data about cardiovascular status and risk factors.

What to include:

• Vital signs (especially blood pressure and heart rate)
• Cardiovascular exam (heart sounds, murmurs, peripheral pulses, edema)
• EKG findings (new or old changes)
• Laboratory results (lipid panel, troponin, BNP if relevant)
• Recent imaging or stress test results
• Body mass index

Examples:

"Vitals: BP 142/88, HR 72 regular, RR 16, O2 sat 97% on room air, BMI 29.3. General: Comfortable at rest. CV: Regular rate and rhythm, normal S1/S2, no murmurs or gallops, JVP not elevated, carotid pulses 2+ without bruits, radial and pedal pulses 2+ bilaterally. Lungs: Clear bilaterally. Extremities: No edema. EKG: Normal sinus rhythm, Q waves in leads II, III, aVF consistent with prior inferior MI, no acute ST changes. Labs: LDL 95 mg/dL, HDL 42 mg/dL, triglycerides 165 mg/dL, HbA1c 6.8%."

"Vitals: BP 118/76, HR 68 regular, BMI 27.8. CV: Regular rate and rhythm, no murmurs, peripheral pulses intact. EKG: NSR, unchanged from prior. Recent stress test: 9 minutes on Bruce protocol, 95% max predicted HR achieved, no chest pain, no ischemic EKG changes, normal perfusion imaging."

3. A - Assessment

This section is your professional assessment of the patient's coronary disease status and risk level.

Purpose: Connect symptoms with findings and evaluate cardiac risk and disease stability.

Key Principle: Focus on disease stability, symptom burden, and risk stratification.

What to include:

• CAD stability (stable vs unstable)
• Angina classification (Canadian Cardiovascular Society class if applicable)
• Risk factor control assessment
• Medication efficacy
• Any changes from baseline

Examples:

"62-year-old male with known CAD status post PCI to LAD 2 years ago, currently with stable angina CCS Class II. Experiencing predictable exertional chest pain relieved by rest, consistent with stable pattern. Blood pressure above goal at 142/88 despite current antihypertensive regimen. LDL at goal below 100 on moderate-intensity statin. Medication adherence good. No evidence of acute coronary syndrome. Risk factors include hypertension (not optimally controlled), hyperlipidemia (controlled), former smoker (quit 6 months ago), BMI 29.3."

"58-year-old female with CAD status post drug-eluting stent to RCA 6 weeks ago, currently asymptomatic on dual antiplatelet therapy. Excellent functional capacity without angina, completing cardiac rehab successfully. All cardiac risk factors well-controlled including blood pressure, lipids, and diabetes. Recent stress test negative for ischemia. Low risk for recurrent events on current medical regimen."

4. P - Plan

This final section outlines your cardiac management strategy.

Purpose: Establish treatment plan for symptom management, risk reduction, and monitoring.

Length: Be specific and comprehensive, typically 4-6 key points for cardiac patients.

What to include:

• Medication adjustments or continuations
• Risk factor modification strategies
• Further testing or referrals if needed
• Follow-up timing
• Patient education on warning signs

Examples:

"Increase metoprolol from 25mg to 50mg twice daily for better blood pressure control and angina symptom management. Continue aspirin 81mg daily, atorvastatin 40mg daily. Optimize blood pressure with addition of lisinopril 10mg daily, goal BP less than 130/80. Patient to monitor home blood pressures and keep log. Continue cardiac rehab exercise program. Reviewed warning signs of unstable angina and when to use nitroglycerin versus calling 911. Follow-up in 6 weeks to reassess angina frequency and blood pressure control. If symptoms increase or become unpredictable, patient to contact office immediately for urgent evaluation."

"Continue current medications: aspirin 81mg daily, clopidogrel 75mg daily (continue for minimum 12 months post-stent), atorvastatin 80mg daily, metoprolol succinate 100mg daily, lisinopril 20mg daily. Patient completing final weeks of cardiac rehab, cleared to continue independent exercise program after graduation. Continue cardiac diet and weight loss efforts with goal of BMI under 25. Repeat lipid panel in 3 months to ensure LDL remains below 70. Routine follow-up in 3 months. Patient educated on importance of dual antiplatelet therapy compliance - emphasized never stopping aspirin or clopidogrel without discussing with cardiologist first. Provided chest pain action plan. Patient to call immediately if experiences chest pain lasting more than 5 minutes despite rest and nitroglycerin."

Complete CAD SOAP Note Examples

Now let's look at three complete examples that bring all these components together.

Example 1: Stable Angina Follow-Up

Patient: 65-year-old male
Visit Type: Routine cardiology follow-up
Chief Complaint: Follow-up for coronary artery disease and stable angina

S – Subjective:

Patient returns for routine CAD follow-up. Reports occasional substernal chest pressure with moderate exertion (walking uphill, carrying groceries), occurring approximately once per week. Describes pressure as 4/10 intensity, non-radiating, lasting 2-3 minutes and resolving completely with rest. Uses sublingual nitroglycerin occasionally with good relief within 1-2 minutes. Denies chest pain at rest, at night, or with minimal exertion. No increase in frequency or severity of symptoms since last visit 4 months ago. Exercise tolerance stable - walks dog 20-30 minutes daily on level ground without symptoms. Denies dyspnea at rest, orthopnea, PND, or palpitations. No lower extremity edema. Taking all medications as prescribed: aspirin 81mg daily, atorvastatin 40mg nightly, metoprolol tartrate 25mg twice daily, isosorbide mononitrate 30mg daily. Monitors blood pressure at home with readings averaging 128-135/75-82. Former smoker, quit 3 years ago, no relapses. Following heart-healthy diet "most of the time" but admits occasional high-sodium meals when eating out. Weight stable at 198 lbs. Denies medication side effects.

O – Objective:

Vitals: BP 132/78, HR 64 regular, RR 14, O2 sat 98% on room air, Weight 198 lbs (unchanged from last visit), BMI 28.7
General: Well-appearing, no acute distress, comfortable at rest
Cardiovascular: Regular rate and rhythm, normal S1/S2, no murmurs, rubs, or gallops, PMI non-displaced, JVP 6cm (normal), carotid upstrokes normal without bruits, radial pulses 2+ bilaterally, dorsalis pedis and posterior tibial pulses 2+ bilaterally
Lungs: Clear to auscultation bilaterally, no wheezes or crackles
Abdomen: Soft, non-tender, no organomegaly, no bruits
Extremities: No peripheral edema, no calf tenderness
EKG: Normal sinus rhythm at 64 bpm, normal axis, Q waves in leads V1-V3 consistent with prior anteroseptal MI from 2018, no acute ST-T wave changes, unchanged from prior EKG 4 months ago
Labs (drawn 1 week ago): Lipid panel: Total cholesterol 168 mg/dL, LDL 92 mg/dL, HDL 44 mg/dL, Triglycerides 160 mg/dL; BMP: Normal renal function, creatinine 1.1 mg/dL; HbA1c 5.9%

A – Assessment:

65-year-old male with history of CAD status post STEMI in 2018 with PCI to LAD (drug-eluting stent), currently with stable angina Canadian Cardiovascular Society (CCS) Class II. Angina pattern predictable and unchanged, occurring with moderate exertion and promptly relieved with rest or nitroglycerin, consistent with stable disease. No evidence of unstable angina or acute coronary syndrome. Blood pressure well-controlled on current regimen, home readings confirm adequate control. LDL at 92 mg/dL, approaching but not yet at optimal goal of less than 70 mg/dL for secondary prevention given history of MI. HDL suboptimal at 44 mg/dL. Medication adherence excellent. Risk factors include hyperlipidemia (partially controlled), overweight BMI 28.7, and low HDL. Former smoking history but sustained abstinence for 3 years is positive. Overall stable cardiac status with acceptable symptom burden on current medical therapy.

P – Plan:

Increase atorvastatin from 40mg to 80mg nightly to achieve LDL goal of less than 70 mg/dL for optimal secondary prevention post-MI. Continue aspirin 81mg daily indefinitely for antiplatelet therapy. Continue metoprolol tartrate 25mg twice daily for heart rate and blood pressure control - current heart rate and BP at goal. Continue isosorbide mononitrate 30mg daily for angina prophylaxis. Consider adding ezetimibe if LDL not at goal on high-intensity statin at next visit. Patient to continue sublingual nitroglycerin 0.4mg as needed for chest pain - reviewed proper use: one tablet under tongue every 5 minutes up to three tablets, call 911 if pain not relieved after first dose. Encouraged continued exercise within symptom limits - current walking routine appropriate. Reinforced importance of heart-healthy diet with emphasis on reducing saturated fats and sodium intake, especially when dining out. Discussed weight loss goal of 10-15 pounds to improve BMI and cardiovascular risk profile - referred to cardiac dietitian for structured meal planning. Repeat lipid panel in 6 weeks to assess response to increased statin dose. Routine follow-up in 4 months or sooner if any change in chest pain pattern. Reviewed warning signs requiring immediate medical attention: chest pain at rest, chest pain lasting more than 10 minutes, chest pain not relieved by rest and nitroglycerin, pain radiating to jaw or left arm, associated shortness of breath, diaphoresis, or nausea. Patient verbalized clear understanding of angina management and when to seek emergency care. Expressed commitment to dietary improvements and medication adherence.

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Example 2: Post-Stent Follow-Up, 6 Weeks

Patient: 58-year-old female
Visit Type: Post-PCI follow-up
Chief Complaint: Follow-up after recent stent placement

S – Subjective:

Patient presents for 6-week follow-up after drug-eluting stent placement to RCA for unstable angina. Reports complete resolution of chest pain since procedure. No chest pain, pressure, or discomfort at rest or with exertion. Completed cardiac rehabilitation program with 12 sessions, now able to walk 45 minutes daily and climb three flights of stairs without symptoms - significant improvement from pre-stent baseline when she had pain with one flight. Denies dyspnea, palpitations, or lightheadedness. No orthopnea or lower extremity edema. Taking all post-PCI medications as prescribed including dual antiplatelet therapy: aspirin 81mg daily and clopidogrel 75mg daily. Also taking atorvastatin 80mg nightly, metoprolol succinate 50mg daily, and lisinopril 10mg daily. Denies any bleeding concerns or easy bruising on antiplatelet therapy. Has not missed any doses of medications. Following cardiac diet strictly since stent, lost 12 pounds. Quit smoking immediately after procedure 6 weeks ago, using nicotine patches with no relapses. Checking blood pressure at home daily with readings 115-125/70-78. Very motivated to prevent future cardiac events.

O – Objective:

Vitals: BP 118/72, HR 62 regular, RR 14, O2 sat 99% on room air, Weight 156 lbs (down from 168 lbs at discharge), BMI 26.2 (down from 28.3)
General: Alert, well-appearing, excellent mood and affect
Cardiovascular: Regular rate and rhythm, normal S1/S2, no murmurs or extra heart sounds, JVP normal at 6cm, peripheral pulses 2+ and symmetric in all extremities, no bruits over carotids or femorals
Lungs: Clear bilaterally, good air exchange
Extremities: No edema, no cyanosis, groin access site well-healed without hematoma or bruit
EKG: Normal sinus rhythm at 62 bpm, normal intervals, no ST segment or T wave abnormalities, resolution of prior T wave inversions in inferior leads that were present pre-intervention
Labs (drawn today): Lipid panel: LDL 68 mg/dL (down from 142 pre-stent), HDL 52 mg/dL, Triglycerides 118 mg/dL; BMP: Normal, creatinine 0.9 mg/dL; CBC: Normal, platelet count 245,000

A – Assessment:

58-year-old female status post successful drug-eluting stent placement to RCA 6 weeks ago for unstable angina, now doing exceptionally well. Complete resolution of angina symptoms with excellent functional capacity, now able to exercise without limitations - significant improvement from pre-intervention baseline. Successful completion of cardiac rehabilitation demonstrating good exercise tolerance and commitment to lifestyle modification. All cardiac medications well-tolerated without adverse effects. Dual antiplatelet therapy ongoing without bleeding complications. Excellent medication adherence reported and confirmed by therapeutic response. LDL now at goal of less than 70 mg/dL on high-intensity statin. Blood pressure well-controlled on current regimen. Impressive lifestyle modifications including 12-pound weight loss and sustained smoking cessation. Low risk for stent thrombosis given adherence to dual antiplatelet therapy and optimal risk factor control. Low risk for recurrent cardiac events based on symptom resolution, functional status, and risk factor management.

P – Plan:

Continue current optimal medical therapy: aspirin 81mg daily indefinitely, clopidogrel 75mg daily (must continue for minimum 12 months post-stent, will reassess at 1 year), atorvastatin 80mg nightly, metoprolol succinate 50mg daily, lisinopril 10mg daily. Strongly emphasized critical importance of dual antiplatelet therapy adherence - educated patient never to stop aspirin or clopidogrel without explicit cardiologist approval, even if other doctors recommend stopping before procedures. Patient verbalized clear understanding and commitment to continuing both medications. Continue independent exercise program - encouraged maintenance of current 45-minute daily walks and consideration of cardiac maintenance exercise classes. Continue cardiac diet and weight loss efforts with goal of additional 10-15 pound loss to achieve ideal body weight. Congratulated patient on smoking cessation success - discussed strategies to maintain abstinence and provided smoking cessation resources for continued support. Repeat lipid panel in 6 months to ensure LDL remains at goal. No further cardiac testing indicated at this time given excellent clinical status. Routine cardiology follow-up in 6 months. Patient to contact office immediately if experiences any chest pain, unusual shortness of breath, palpitations, syncope, or concerning bleeding. Reviewed signs of stent thrombosis (sudden onset severe chest pain) requiring immediate 911 call. Patient expressed gratitude for care and strong commitment to maintaining lifestyle changes and medication adherence.

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Example 3: Chest Pain Evaluation, New Diagnosis

Patient: 71-year-old male
Visit Type: Urgent cardiology consultation
Chief Complaint: Chest pain with exertion over past 3 weeks

S – Subjective:

Patient referred by PCP for cardiology evaluation of exertional chest pain. Reports onset of substernal chest pressure 3 weeks ago while mowing lawn. Describes sensation as "heavy pressure" rated 6-7/10, non-radiating, associated with mild dyspnea and diaphoresis. Episode lasted approximately 10 minutes, resolved with rest. Since initial episode, has experienced similar symptoms 4-5 times, always with moderate to vigorous exertion (climbing stairs, walking uphill, yard work). No chest pain at rest or during minimal activity. Symptoms consistently resolve with 5-10 minutes of rest. Denies chest pain at night. Never used nitroglycerin. Somewhat anxious about symptoms but continued usual activities until PCP visit yesterday. No prior cardiac history, no prior stress tests or cardiac catheterization. Denies orthopnea, PND, or lower extremity edema. Currently taking lisinopril 10mg daily for hypertension diagnosed 5 years ago, atorvastatin 20mg nightly started 2 years ago for high cholesterol. Medical history includes hypertension, hyperlipidemia, and Type 2 diabetes controlled on metformin. Family history significant for father who died of MI at age 68 and brother with CABG at age 65. Former smoker, quit 10 years ago, 30 pack-year history. Denies alcohol or drug use.

O – Objective:

Vitals: BP 148/92, HR 82 regular, RR 16, O2 sat 97% on room air, Weight 215 lbs, Height 5'10", BMI 30.8
General: Obese male, well-appearing, no acute distress at rest
Cardiovascular: Regular rate and rhythm, normal S1/S2, no murmurs, rubs, or gallops, PMI non-displaced, JVP 7cm, carotid upstrokes normal with bilateral carotid bruits noted on auscultation, radial pulses 2+ bilaterally, dorsalis pedis pulses 1+ bilaterally (diminished), posterior tibial pulses 1+ bilaterally
Lungs: Clear to auscultation bilaterally
Abdomen: Obese, soft, non-tender, no masses
Extremities: No edema, no clubbing, no cyanosis
EKG (in office today): Normal sinus rhythm at 82 bpm, normal axis, normal intervals, no Q waves, no ST elevations, minimal nonspecific T wave flattening in leads V5-V6, no acute ischemic changes
Labs (drawn by PCP yesterday): Lipid panel: Total cholesterol 198 mg/dL, LDL 128 mg/dL, HDL 38 mg/dL, Triglycerides 210 mg/dL; Fasting glucose 142 mg/dL, HbA1c 7.4%; Creatinine 1.2 mg/dL, eGFR 62 mL/min; Troponin: negative (less than 0.01 ng/mL)

A – Assessment:

71-year-old male with multiple cardiac risk factors (hypertension, hyperlipidemia, Type 2 diabetes, obesity, former smoker, family history of premature CAD) presenting with new onset typical exertional angina over past 3 weeks, concerning for significant coronary artery disease. Chest pain pattern is classic for stable angina: predictable, exertional, substernal pressure with consistent duration and relief pattern. No features of unstable angina (pain at rest, crescendo pattern, prolonged duration) and negative troponin rule out acute MI. However, new onset angina within past 2 months warrants urgent further evaluation per ACC/AHA guidelines. Physical exam findings of carotid bruits and diminished pedal pulses suggest systemic atherosclerosis. Multiple suboptimally controlled risk factors including blood pressure 148/92 (above goal), LDL 128 (not at goal for diabetic patient), HbA1c 7.4% (above goal), BMI 30.8 (obese), and low HDL 38. High pretest probability for obstructive CAD given age, symptoms, and risk factor burden. Requires urgent stress testing or coronary angiography for risk stratification and treatment planning.

P – Plan:

Given new onset typical angina with high pretest probability for CAD, scheduled for pharmacologic stress test with imaging (patient unable to achieve adequate heart rate on treadmill given deconditioning) within 48 hours. Will obtain adenosine nuclear stress test to assess for inducible ischemia and determine extent/severity of coronary disease. Started medical therapy today: aspirin 81mg daily for antiplatelet effect, increased atorvastatin from 20mg to 40mg for aggressive lipid lowering, continue lisinopril 10mg daily. Prescribed sublingual nitroglycerin 0.4mg to carry at all times - instructed to take one tablet under tongue at onset of chest pain, may repeat every 5 minutes up to three tablets. If pain not improved after first dose, call 911 immediately - do not drive self to hospital. Educated on recognition of ACS symptoms: chest pain at rest, pain lasting more than 20 minutes, pain associated with nausea/vomiting, new-onset severe dyspnea. Patient to present to ED immediately if these occur. Activity restriction: avoid strenuous exertion until stress test completed and results reviewed - no mowing lawn, no heavy lifting, no vigorous exercise. Discussed that based on stress test results, may need cardiac catheterization for definitive diagnosis and potential intervention. Addressed cardiovascular risk factors: increase lisinopril to 20mg daily for better blood pressure control (goal less than 130/80 in diabetic patient), will consider adding additional antihypertensive if BP not controlled. Referred to endocrinology for diabetes optimization given suboptimal control. Strongly encouraged dietary modifications: low saturated fat, low sodium cardiac diet with referral to dietitian for comprehensive counseling and weight loss program (goal BMI under 25). Will recheck lipid panel in 6 weeks after statin increase with goal LDL less than 70 given diabetes. Urgent follow-up scheduled in 3 days to review stress test results and determine next steps. Patient provided with detailed written instructions on medication use, activity restrictions, and warning signs. Patient and wife present for discussion, both verbalized understanding and expressed appropriate concern. Emphasized importance of stress test attendance and medication compliance. Patient to call office immediately with any concerns or worsening symptoms before scheduled follow-up.

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Additional Tips for CAD SOAP Notes

Characterize Chest Pain Thoroughly: Use OPQRST (Onset, Provocation, Quality, Radiation, Severity, Timing) to document chest pain completely. This helps differentiate stable from unstable disease.

Document Functional Class: Use Canadian Cardiovascular Society (CCS) classification for angina when applicable. Insurance and specialists want to know symptom burden objectively.

Medication Compliance: Always document adherence to antiplatelet agents and statins specifically. These are the most critical medications for secondary prevention.

Risk Factor Control: Document all modifiable risk factors and whether they're at goal. This justifies ongoing medical management and interventions.

Cardiac History: Include prior MIs, PCIs, CABG, and dates. This context is essential for risk stratification and treatment decisions.

Stress Testing: When referencing stress tests, include key details: protocol used, duration, heart rate achieved, symptoms during test, EKG changes, and imaging results.

Dual Antiplatelet Therapy: For post-stent patients, explicitly document duration of DAPT and emphasize importance of compliance. This is a huge medicolegal and patient safety issue.

Follow-Up Timing: Justify your follow-up interval based on stability. Unstable symptoms warrant days to weeks, stable patients can go 3-6 months.

Implementing structured SOAP notes in your CAD practice ensures comprehensive cardiac care, demonstrates appropriate risk stratification, and provides clear documentation for insurance requirements and continuity of care.