The Quick Guide to DVT SOAP Note Examples for Healthcare Providers

If you've ever struggled to document deep vein thrombosis cases in a way that justifies treatment decisions while meeting insurance requirements, this guide is for you.

I've talked to countless emergency physicians, hospitalists, and primary care providers who know the clinical presentation of DVT inside and out, but struggle with documentation that satisfies insurance scrutiny for anticoagulation approval and specialist referrals.

The reality is that DVT documentation has specific requirements that go beyond basic medical notes.

Insurance companies want to see clear risk stratification using Wells criteria, appropriate diagnostic imaging interpretation, documented bleeding risk assessment, and justification for anticoagulation choices.

That's exactly why I built SOAP Notes Doctor to handle the documentation burden while you focus on timely diagnosis and treatment.

In this article, I'll show you exactly how to write DVT SOAP notes that meet insurance standards, with real examples you can use as templates.

🧾 What SOAP Notes Really Are (And Why They Matter for DVT)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose when documenting thromboembolic disease.

They were introduced in the 1960s by Dr. Lawrence Weed as part of the Problem-Oriented Medical Record (POMR).

His goal was straightforward: create a documentation system that anyone reviewing a chart could understand quickly and completely.

For DVT specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of clinical probability and risk assessment
• Appropriate use of diagnostic imaging (ultrasound, D-dimer)
• Justified anticoagulation therapy selection and dosing
• Medical necessity for specialist consultation or extended treatment
• Assessment of bleeding risk and contraindications

SOAP stands for:

• S — Subjective: What the patient reports about leg pain, swelling, recent immobility, risk factors, and symptom timeline.
• O — Objective: Your clinical findings including vitals, physical exam (leg circumference, Homan's sign, skin changes), Wells score, D-dimer, and ultrasound results.
• A — Assessment: Your clinical diagnosis with probability assessment, DVT location and extent, risk stratification, and treatment plan rationale.
• P — Plan: Your treatment plan including anticoagulation choice, dosing, monitoring parameters, activity restrictions, compression therapy, and follow-up.

This structure keeps your documentation organized, defensible, and insurance-friendly.

You're not just recording what happened—you're building a clinical narrative that justifies immediate anticoagulation and ongoing treatment decisions.

How You Can Approach DVT SOAP Notes

There's no single correct method for writing DVT SOAP notes, but some approaches work better than others depending on your practice setting.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: typing out each section after diagnosis. It works if you have strong clinical writing skills and time built into your workflow. The challenge is it's time-consuming, especially in busy emergency departments or urgent care settings where DVT patients need rapid treatment initiation.

2. SOAP Notes Doctor

You record your examination findings or dictate your observations, and the tool automatically structures everything into proper SOAP format. It maintains consistency, saves time in high-pressure situations, and ensures you never miss critical components that insurance companies look for in DVT management.

How to Make DVT SOAP Notes Faster

One of the biggest complaints I hear from providers managing suspected DVT is how documentation delays treatment.

You've just confirmed a lower extremity DVT on ultrasound, the patient needs anticoagulation started immediately, and you still need to complete comprehensive documentation for the medical record and insurance.

The pressure is real: make notes too brief and you risk denials for expensive anticoagulants like DOACs; make them too detailed and you've delayed treatment while typing.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your examination findings or dictate key observations
✅ Generate properly formatted SOAP notes instantly
✅ Get back to treating patients quickly

With soapnotes.doctor, you can record during or right after evaluation, add rough notes about specific findings, or even upload audio later. The system converts everything into insurance-compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness that insurance companies require, but without manually typing every detail.

Maybe you noted specific findings?

"Left calf swelling 3cm larger than right, positive Homan's sign, Wells score 4, D-dimer 2400, ultrasound shows non-compressible popliteal and posterior tibial veins."

Use the tailorr feature to add them. Keep it raw and unpolished—soapnotes.doctor handles the rest.

Example 1: Acute Lower Extremity DVT, Emergency Department

Patient: 52-year-old female
Chief Complaint: Left leg swelling and pain for 2 days
Visit: Emergency department evaluation

S – Subjective:

Patient presents with progressive left lower extremity swelling and pain that began 2 days ago. Describes dull, aching pain in left calf, worse with walking. Noticed leg felt "tight" and swollen yesterday morning. Recent 8-hour car trip from Florida 5 days ago. No recent surgery or trauma. No chest pain or shortness of breath. No history of prior DVT or PE. Currently taking oral contraceptive pills for past 3 years. No family history of clotting disorders. Denies recent bleeding episodes.

O – Objective:

Vital Signs: BP 132/84, HR 88, RR 16, Temp 98.4°F, O2 sat 98% on room air
Left lower extremity: Edema from mid-calf to ankle, calf circumference 39cm (right calf 36cm, 3cm difference), warmth and tenderness to palpation over posterior calf, mild erythema, palpable cord, positive Homan's sign
Right lower extremity: No edema, no tenderness
Lungs: Clear bilaterally
Wells Score: 3 points (calf swelling >3cm, pitting edema, tenderness along deep veins) = Moderate probability
D-dimer: 2,680 ng/mL (elevated)
Venous Duplex Ultrasound: Non-compressible left popliteal and posterior tibial veins with absent flow, consistent with acute DVT. No extension into femoral vein. Right leg normal.

A – Assessment:

52-year-old female with acute left lower extremity DVT involving popliteal and posterior tibial veins. Provoked DVT with risk factors including recent prolonged immobility (long car trip) and oral contraceptive use. Moderate clinical probability confirmed by imaging. No evidence of pulmonary embolism on clinical assessment. Low bleeding risk, appropriate candidate for outpatient anticoagulation.

P – Plan:

Initiated anticoagulation with apixaban 10mg PO BID for 7 days, then 5mg BID ongoing. Advised discontinuation of oral contraceptive pills and discussed alternative contraception methods. Prescribed compression stockings 20-30 mmHg for symptomatic relief. Encouraged leg elevation and ambulation as tolerated. Patient education provided on DVT, warning signs of pulmonary embolism (chest pain, shortness of breath, hemoptysis), and bleeding precautions while on anticoagulation. Follow-up with primary care physician in 1 week and with hematology in 2-3 weeks to discuss duration of anticoagulation (likely 3 months for provoked DVT). Instructed to return immediately if worsening leg symptoms, chest pain, or dyspnea. Patient verbalized understanding and was discharged home in stable condition.

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Example 2: Suspected DVT, Low Probability, Ruled Out

Patient: 38-year-old male
Chief Complaint: Right calf pain after running
Visit: Urgent care evaluation

S – Subjective:

Patient presents with right calf pain that started yesterday after 5-mile run. Describes sharp, cramping pain localized to medial calf muscle. Denies swelling, redness, or warmth. No recent travel or immobility. Very active, runs 20-30 miles weekly. No personal or family history of blood clots. No recent surgery. Takes no medications. Pain improved with rest and ibuprofen but still present.

O – Objective:

Vital Signs: BP 118/72, HR 64, RR 14, Temp 98.2°F
Right lower extremity: No visible edema, calf circumference 36cm (left 36cm, no difference), mild tenderness to deep palpation over medial gastrocnemius muscle, no warmth, no erythema, negative Homan's sign, full ROM of ankle
Left lower extremity: Normal
Wells Score: 0 points = Low probability
D-dimer: Not ordered (Wells score low, clinical suspicion minimal)

A – Assessment:

38-year-old male with right calf pain consistent with muscle strain from overuse/running. Low pretest probability for DVT based on Wells criteria and clinical presentation. No risk factors for thromboembolism. Physical exam findings more consistent with musculoskeletal etiology.

P – Plan:

Reassured patient that presentation not concerning for DVT. Diagnosed with gastrocnemius muscle strain. Recommended rest, ice, compression, and elevation (RICE protocol). Continue ibuprofen 400mg every 6-8 hours as needed for pain. Gradual return to running activity as pain improves. Educated patient on true warning signs of DVT including unilateral leg swelling, warmth, erythema, and cord-like structures. Instructed to return if symptoms worsen or new swelling develops. Follow-up as needed.

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Example 3: Recurrent DVT on Anticoagulation

Patient: 64-year-old male
Chief Complaint: Right leg swelling, history of DVT
Visit: Vascular surgery clinic

S – Subjective:

Patient with history of right lower extremity DVT 8 months ago, currently on rivaroxaban 20mg daily. Presents with 3 days of increasing right leg swelling and heaviness. Denies calf pain but notes leg feels "full." Reports good medication compliance, takes rivaroxaban every morning with breakfast. No recent trauma. No missed doses. Denies chest pain or dyspnea. Previous DVT was unprovoked, currently on indefinite anticoagulation per hematology recommendation.

O – Objective:

Vital Signs: BP 138/86, HR 76, RR 16, O2 sat 97% on room air
Right lower extremity: Moderate edema from ankle to mid-thigh, calf circumference 41cm (left 37cm, 4cm difference), mild tenderness, no significant warmth or erythema
Recent labs: INR not applicable (on DOAC), Creatinine 1.1 mg/dL, Platelets 210,000
Venous Duplex Ultrasound: Acute thrombus in right common femoral vein with extension into external iliac vein. Chronic changes in popliteal vein from prior DVT. Left leg normal.

A – Assessment:

64-year-old male with recurrent right lower extremity DVT despite therapeutic anticoagulation with rivaroxaban. Current DVT involves proximal veins (common femoral and external iliac), more extensive than prior episode. Concerning for anticoagulation failure or underlying hypercoagulable state. Requires intensification of anticoagulation and hematology re-evaluation.

P – Plan:

Admitted to hospital for transition to unfractionated heparin infusion with goal PTT 60-80 seconds. Hematology consulted for management of recurrent VTE on anticoagulation. Plan for hypercoagulable workup including Factor V Leiden, Prothrombin gene mutation, antiphospholipid antibodies, protein C/S, antithrombin III once acute event resolves. IVC filter evaluation discussed with patient given recurrent thrombosis on anticoagulation. Long-term plan will involve switching to different anticoagulation strategy, possibly LMWH or warfarin with target INR 2.5-3.5. Patient educated on serious nature of recurrent thrombosis and importance of close follow-up.

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Key Components Insurance Companies Look For in DVT SOAP Notes

When reviewing your DVT documentation, insurance companies specifically want to see:

1. Clinical Probability Assessment

Document Wells criteria or other validated scoring system. This justifies whether you ordered D-dimer or went straight to imaging.

2. Risk Factor Documentation

Identify provoked vs. unprovoked DVT. Document recent surgery, travel, immobility, malignancy, pregnancy, oral contraceptives, or prior VTE history.

3. Diagnostic Testing Justification

Clear documentation of why you ordered D-dimer, ultrasound, or other imaging based on pretest probability.

4. Anticoagulation Choice Rationale

Document why you chose specific anticoagulation (DOAC vs. warfarin vs. LMWH) based on renal function, bleeding risk, drug interactions, and patient factors.

5. Bleeding Risk Assessment

Document any contraindications to anticoagulation or factors increasing bleeding risk (recent surgery, GI bleeding, thrombocytopenia, falls).

6. Duration of Treatment Plan

Document whether DVT is provoked or unprovoked and planned duration of anticoagulation (3 months, 6 months, indefinite).

Common Mistakes to Avoid

Missing Wells Score: Always document clinical probability assessment—insurance wants objective risk stratification, not just clinical gestalt.

Vague Symptom Timeline: Document exactly when symptoms began and how they've progressed. This affects treatment decisions and risk assessment.

No Bleeding Risk Documentation: Before starting anticoagulation, document you've assessed bleeding risk and contraindications.

Incomplete Physical Exam: Always document bilateral leg examination with calf measurements, even if only one leg is symptomatic.

Forgetting Leg Measurements: Calf or thigh circumference difference between legs is objective data insurance companies look for.

No Anticoagulation Justification: When choosing expensive DOACs over warfarin, document why (patient preference, no monitoring access, drug interactions, etc.).

Missing Provoked vs. Unprovoked Classification: This determines treatment duration and affects insurance approval for long-term anticoagulation.

Final Thoughts

DVT SOAP notes don't need to be overwhelming.

They need to be thorough, yes, but they don't need to delay critical treatment.

The key is having a system that captures the right information without making you spend 20 minutes typing while your patient waits for anticoagulation.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that serves your patient and satisfies insurance requirements.

Your time is better spent ensuring rapid diagnosis and treatment than fighting with documentation.

That's exactly why we built this tool.

Try it out, see how much time you get back, and let me know what you think.

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Ready to simplify your DVT documentation?
Visit soapnotes.doctor and get your first notes generated in minutes.