Quick Way to Write MI SOAP Note Examples for Healthcare Providers

MI SOAP Note Examples

It's 2 AM in the ED, you've just stabilized a STEMI patient, and now you need to document everything that happened.

Your adrenaline is still pumping from the code, you've got three other patients waiting, and you need to write a note that captures the critical decision-making that could make or break a lawsuit someday.

The cardiologist is asking for your documentation, the cath lab team needs details, and insurance will scrutinize every medication choice.

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 capture your critical details during or after the acute event 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 emergency documentation was all over the place.

One doctor might write "chest pain - possible MI - sent to cath lab" while another would write pages about every subtle finding without clearly stating the diagnosis.

When time is critical and lives are on the line, you can't afford ambiguous documentation.

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

His brilliant idea was simple: standardize documentation so that anyone picking up the chart immediately understands what's happening, what was done, and what comes next.

Here's what Dr. Weed came up with:

• S (Subjective): What the patient tells you about their symptoms
• O (Objective): What you observe, measure, and test
• A (Assessment): Your clinical diagnosis and risk assessment
• P (Plan): Your treatment and next steps

This format became essential in emergency cardiac care because it forces you to document the critical elements in a logical sequence.

For MI specifically, this structure helps you capture symptom onset time (crucial for treatment windows), physical findings, EKG changes, biomarkers, and treatment decisions - all in a way that proves you met the standard of care.

How to Write MI SOAP Notes: My Recommended Approach

When I started working with cardiologists and emergency physicians, I noticed they'd stress about documentation even after saving lives.

Then I figured out what actually matters:

"Document the timeline, the decision-making, and the response. Everything else is secondary."

For MI notes, you need: symptom onset time, EKG findings, troponin levels, time to treatment, and patient response. Get those right and you've covered the essentials.

I built soapnotes.doctor around this principle - capture what matters, fast.

There are technically two ways you can approach MI 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 when you're managing an MI, the last thing you need is to spend 30 minutes typing a note.

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 capture your findings during or immediately after the acute event.

3. Wait 1-3 minutes.

4. Review and save.

One beauty of soapnotes.doctor is that it captures the critical timeline elements automatically. Not overly verbose, yet never misses the details that matter for legal protection and quality metrics.

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 managing this on paper in the ED or you want to write it yourself. Here's how to do it efficiently without missing critical elements.

1. S - Subjective

This is where you capture the patient's description of their symptoms and the timeline.

This section should document the patient's chief complaint, symptom onset, and cardiac risk factors.

Purpose: Establish the timeline and symptom pattern that drove your clinical decision-making.

What to include:

• Chief complaint (be specific: "crushing chest pain" not just "chest pain")
• Exact time of symptom onset (critical for treatment windows)
• Character, location, radiation, severity (0-10 scale)
• Associated symptoms (dyspnea, diaphoresis, nausea, palpitations)
• Aggravating/alleviating factors
• Previous cardiac history
• Risk factors (HTN, DM, smoking, family history, hyperlipidemia)
• Current medications

Examples:

"62-year-old male presents with sudden onset severe crushing substernal chest pain that began at 8:45 AM (approximately 2 hours ago). Rates pain 9/10, radiating to left arm and jaw. Associated with diaphoresis, nausea, and shortness of breath. Pain not relieved by rest or three doses of sublingual nitroglycerin taken at home. Denies prior episodes. History of hypertension and hyperlipidemia, takes lisinopril and atorvastatin. 30 pack-year smoking history. Father died of MI at age 58."

"71-year-old female with history of CAD s/p PCI to LAD 3 years ago presents with recurrent chest pressure that began 6 hours ago during sleep. Describes pressure as 6/10, substernal, with radiation to both shoulders. Associated with dyspnea and lightheadedness. Similar to her previous MI symptoms. Takes aspirin, metoprolol, and Plavix daily. History of diabetes and hypertension."

2. O - Objective

This is where you document your clinical findings and test results.

The objective section captures vitals, physical exam, EKG findings, and lab results.

Purpose: Document measurable data that supports your diagnosis and treatment decisions.

What to include:

• Vital signs (note any instability)
• General appearance
• Cardiovascular exam findings
• Lung sounds
• EKG interpretation with specific findings
• Cardiac biomarkers (troponin, CK-MB if used)
• Other relevant labs
• Imaging results

Examples:

"Vitals: BP 168/95, HR 102 irregular, RR 24, O2 sat 92% on room air, Temp 98.6°F. Patient appears distressed, diaphoretic, clutching chest. Cardiovascular: Irregularly irregular rhythm, no murmurs or gallops appreciated, JVP not elevated. Lungs: Bilateral crackles in lower fields. Extremities: No edema, peripheral pulses intact. EKG: ST elevation 3mm in leads II, III, aVF with reciprocal ST depression in I, aVL consistent with inferior STEMI. Troponin I: 2.8 ng/mL (elevated). BNP 450 pg/mL. CXR: No acute infiltrates, mild pulmonary congestion."

"Vitals: BP 95/60, HR 115, RR 22, O2 sat 94% on 4L NC. Patient appears pale, anxious, in moderate distress. Cardiovascular: Tachycardic, regular rhythm, S3 gallop present, no murmurs. Lungs: Clear bilaterally. Extremities: Cool, clammy skin, weak peripheral pulses. EKG: ST elevation 2-3mm in V1-V4 consistent with anterior STEMI, new Q waves in V2-V3. First troponin: 8.4 ng/mL (significantly elevated). Second troponin (3 hours later): 15.2 ng/mL (rising). Creatinine 1.4 mg/dL, K+ 4.0 mEq/L."

3. A - Assessment

This section is your clinical diagnosis and risk stratification.

Purpose: State your diagnosis clearly and assess the severity and complications.

Key Principle: Be definitive when appropriate, document your clinical reasoning.

What to include:

• Specific diagnosis (STEMI vs NSTEMI, location of infarct)
• Risk stratification (TIMI score, Killip class if applicable)
• Complications identified
• Differential diagnoses considered

Examples:

"Inferior STEMI with symptom onset approximately 2 hours ago, within treatment window for reperfusion therapy. EKG shows ST elevation in inferior leads (II, III, aVF) with reciprocal changes. Elevated troponin confirms myocardial injury. Patient hemodynamically stable at present (Killip Class I). High-risk features include advanced age, smoking history, and strong family history. Candidate for emergent cardiac catheterization."

"Anterior STEMI complicated by cardiogenic shock. Extensive ST elevation in anterior leads with Q wave development suggests large area of myocardium at risk. Significantly elevated and rising troponin. Physical exam findings (hypotension, tachycardia, S3 gallop, cool extremities) consistent with cardiogenic shock, Killip Class IV. Requires urgent revascularization and hemodynamic support."

4. P - Plan

This final section outlines your immediate treatment and ongoing management.

Purpose: Document time-critical interventions and continuing care plan.

Length: Be thorough but organized - this is life-saving treatment documentation.

What to include:

• Immediate interventions with times
• Medications administered
• Reperfusion strategy and timing
• Consultations and transfers
• Monitoring plan
• Patient/family communication

Examples:

"Activated STEMI protocol at 10:52 AM. Administered aspirin 324mg PO, ticagrelor 180mg loading dose, heparin 4000 unit IV bolus. Started nitroglycerin drip for blood pressure control. Morphine 4mg IV for pain control. Cardiology consulted, cath lab activated. Door-to-balloon time goal less than 90 minutes. Patient transferred to cath lab at 11:15 AM. Discussed risks, benefits, and alternatives with patient and family; patient gave verbal consent for emergent catheterization given clinical situation. Will continue aspirin, P2Y12 inhibitor, beta blocker, statin, and ACE inhibitor post-procedure. Admit to CCU post-cath for monitoring."

"Time-critical interventions: Aspirin 324mg PO given at 11:05. Started dual antiplatelet therapy with ticagrelor 180mg loading dose. Heparin bolus 5000 units IV followed by infusion. Beta blocker held due to hypotension. Started norepinephrine drip for hemodynamic support, titrating to MAP greater than 65. Cardiology at bedside, emergent cath lab activated for cardiogenic shock protocol. Placed on 100% non-rebreather, O2 sat improved to 96%. Discussed critical nature of situation with family. Patient intubated at 11:30 for airway protection prior to cath. IABP placed in cath lab. Successful PCI to LAD performed. Transferred to CCU on pressors and ventilator support."

Complete MI SOAP Note Examples

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

Example 1: Uncomplicated Inferior STEMI

Patient: 58-year-old male
Arrival Time: 10:30 AM via EMS
Chief Complaint: Chest pain
Door-to-EKG Time: 6 minutes

S – Subjective:

58-year-old male brought in by EMS with chief complaint of severe chest pain. Patient reports pain began suddenly at 9:45 AM (approximately 45 minutes ago) while mowing lawn. Describes pain as "crushing" and "like an elephant sitting on my chest," substernal, radiating to left shoulder and jaw. Rates pain 10/10 at onset, currently 8/10 despite sublingual nitroglycerin given by EMS. Associated with profuse diaphoresis, nausea (vomited once), and shortness of breath. Denies prior episodes of chest pain. Past medical history significant for hypertension diagnosed 5 years ago, hyperlipidemia on statin therapy, and prediabetes. Takes lisinopril 20mg daily and atorvastatin 40mg nightly. Non-compliant with medications "sometimes forgets." Current smoker, 1 pack per day for 35 years. Denies alcohol or illicit drug use. Family history significant for father with MI at age 62 and brother with MI at age 54. Denies recent cocaine use. Last ate breakfast at 7 AM.

O – Objective:

Initial Assessment 10:36 AM:
Vitals: BP 152/88, HR 96 regular, RR 20, O2 sat 94% on room air (improved to 98% on 4L NC), Temp 98.4°F
General: Middle-aged male in obvious distress, diaphoretic, anxious, clutching chest
HEENT: Mucous membranes moist, no JVD elevation noted
Cardiovascular: Regular rate and rhythm, normal S1/S2, no murmurs, rubs, or gallops, PMI non-displaced, peripheral pulses 2+ and symmetric
Pulmonary: Clear to auscultation bilaterally, no rales, wheezes, or rhonchi, good air movement
Abdomen: Soft, non-tender, non-distended, normal bowel sounds
Extremities: No edema, no cyanosis, skin cool and diaphoretic
Neurological: Alert and oriented x3, appropriate responses

EKG 10:36 AM: Sinus rhythm at 96 bpm, ST segment elevation 3mm in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. No prior EKG available for comparison. Interpretation: Acute inferior STEMI.

Labs drawn 10:40 AM:
Troponin I: 0.8 ng/mL (elevated, normal less than 0.04)
CK: 245 U/L
CK-MB: 18 ng/mL (elevated)
CBC: WBC 12.3, Hgb 14.2, Plt 285 (normal)
BMP: Na 138, K 4.2, Cl 102, CO2 24, BUN 18, Cr 1.0, Glucose 156
Coagulation: PT 12.1, INR 1.0, PTT 28

Chest X-ray 10:45 AM: Normal cardiac silhouette, clear lung fields, no acute process

A – Assessment:

58-year-old male presenting with acute inferior ST-elevation myocardial infarction (STEMI) with symptom onset 45 minutes prior to arrival. EKG demonstrates classic ST elevation in inferior leads (II, III, aVF) with reciprocal changes in lateral leads, consistent with right coronary artery or left circumflex occlusion. Elevated cardiac biomarkers confirm acute myocardial injury. Patient is within treatment window for reperfusion therapy (symptom-to-door time 45 minutes). Currently hemodynamically stable, Killip Class I (no signs of heart failure). Multiple cardiac risk factors including hypertension, hyperlipidemia, smoking (35 pack-years), prediabetes, and strong family history of early CAD. Meets criteria for emergent cardiac catheterization with goal door-to-balloon time less than 90 minutes.

P – Plan:

STEMI Protocol Activated 10:36 AM:

Immediate Interventions:

• Aspirin 324mg PO chewed and swallowed (given 10:38 AM)
• Ticagrelor 180mg PO loading dose (given 10:40 AM)
• Heparin 5000 unit IV bolus followed by 1000 units/hour infusion (started 10:41 AM)
• Morphine 4mg IV push for pain relief (given 10:42 AM, pain reduced to 5/10)
• Supplemental oxygen via nasal cannula maintaining O2 sat greater than 94%
• Sublingual nitroglycerin 0.4mg x1 (BP tolerated, gave second dose at 10:50)
• Metoprolol 5mg IV push (given 10:55 AM given stable hemodynamics)
• Atorvastatin 80mg PO (high-intensity statin initiated)

Cardiology Consultation: Dr. Johnson paged 10:37 AM, at bedside 10:48 AM, agrees with STEMI diagnosis and plan for emergent catheterization

Cath Lab Activation: Cath lab team activated 10:38 AM, team assembled and ready 11:05 AM

Patient/Family Communication: Explained diagnosis of heart attack to patient and wife, discussed need for emergent cardiac catheterization to open blocked artery, reviewed risks including bleeding, stroke, need for emergency bypass surgery, and death. Patient and family expressed understanding. Given critical nature and time-sensitive intervention, obtained verbal consent documented in chart.

Transfer to Cath Lab: Patient transferred to cath lab 11:10 AM (door-to-balloon time goal less than 90 minutes on track)

Post-Procedure Plan:

• Continue dual antiplatelet therapy: aspirin 81mg daily indefinitely, ticagrelor 90mg BID for minimum 12 months
• Continue metoprolol, titrate to resting HR 50-60
• Continue high-intensity statin (atorvastatin 80mg nightly)
• Initiate ACE inhibitor (lisinopril) post-procedure if BP tolerates
• Admit to Cardiac Care Unit for continuous telemetry monitoring minimum 24 hours
• Serial troponins q8h x3
• Echocardiogram in AM to assess ventricular function and wall motion abnormalities
• Cardiac rehabilitation referral
• Smoking cessation counseling and resources
• Patient education on medication compliance and lifestyle modifications

Critical Follow-Up: Patient to follow up with cardiology in 1 week post-discharge for medication adjustment and risk factor modification.

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Example 2: NSTEMI in Elderly Patient

Patient: 76-year-old female
Arrival Time: 2:15 PM via private vehicle
Chief Complaint: Chest discomfort and weakness
Setting: Emergency Department

S – Subjective:

76-year-old female with history of coronary artery disease status post PCI to LAD 4 years ago presents with complaints of intermittent chest discomfort and generalized weakness over past 8 hours. Patient describes discomfort as "pressure" and "heaviness" in center of chest, rating severity 5-6/10. Symptoms waxing and waning, worse with minimal exertion like walking to bathroom. Associated with dyspnea on exertion, diaphoresis, and profound fatigue. Denies nausea, vomiting, or radiation of pain. States symptoms similar to but "not quite as severe" as her previous heart attack 4 years ago. Initially attributed symptoms to "indigestion" and took antacids without relief. Past medical history includes CAD s/p PCI with drug-eluting stent to LAD (2021), type 2 diabetes mellitus, hypertension, chronic kidney disease stage 3, and hyperlipidemia. Current medications: aspirin 81mg daily, clopidogrel 75mg daily, metoprolol succinate 50mg daily, lisinopril 10mg daily, atorvastatin 40mg nightly, metformin 1000mg BID. States she takes all medications as prescribed. Non-smoker, rare alcohol use. Family history significant for mother with MI at age 70. Denies recent medication changes or missed doses. Lives alone, daughter brought her to ED when patient called reporting feeling "very weak."

O – Objective:

Initial Assessment 2:20 PM:
Vitals: BP 102/58, HR 58 regular, RR 18, O2 sat 96% on room air, Temp 97.8°F
General: Elderly female, appears fatigued but not in acute distress at rest, skin cool to touch
HEENT: Mucous membranes slightly dry, JVP difficult to assess
Cardiovascular: Bradycardic, regular rhythm, normal S1/S2, no murmurs or gallops, distal pulses diminished but palpable
Pulmonary: Clear to auscultation bilaterally, no increased work of breathing
Abdomen: Soft, non-tender, non-distended
Extremities: No edema, no cyanosis
Neurological: Alert and oriented x3, slightly slow to respond but appropriate

EKG 2:22 PM: Sinus bradycardia at 58 bpm, normal axis, Q waves in V1-V3 (old, consistent with prior anteroseptal MI), ST depression 1-2mm in leads V4-V6 and I, aVL (new compared to EKG from 6 months ago on file), T wave inversions in lateral leads

Labs drawn 2:25 PM:
Initial Troponin I: 1.2 ng/mL (elevated)
Repeat Troponin I (5 hours later, 7:30 PM): 2.8 ng/mL (rising, confirms acute MI)
BNP: 620 pg/mL (elevated)
CBC: WBC 9.8, Hgb 11.2 (baseline anemia), Plt 198
CMP: Na 136, K 4.5, Cl 98, CO2 22, BUN 32, Cr 1.6 (baseline 1.4-1.5), Glucose 178
eGFR: 38 mL/min (consistent with known CKD stage 3)

Chest X-ray 2:35 PM: Mild cardiomegaly, no acute infiltrates, no pulmonary edema

A – Assessment:

76-year-old female with significant cardiac history including prior PCI presenting with Non-ST-Elevation Myocardial Infarction (NSTEMI). Clinical presentation of prolonged chest discomfort with exertional component, new ST depressions on EKG, and elevated troponin that rises on serial testing confirms acute coronary syndrome. GRACE risk score calculated at 142 (high risk). Patient has multiple high-risk features including advanced age, diabetes, chronic kidney disease, prior CAD with stenting, and current bradycardia limiting beta blocker optimization. New ST changes suggest ischemia in distribution possibly beyond previously stented vessel. Currently hemodynamically stable though relative hypotension and bradycardia present, likely related to beta blocker therapy in setting of acute illness. Mild renal dysfunction will require contrast minimization strategies and hydration protocol if pursuing catheterization. Given high-risk features and rising troponin, patient is candidate for early invasive strategy with coronary angiography within 24-48 hours rather than immediate catheterization.

P – Plan:

Acute Coronary Syndrome Protocol Initiated:

Immediate Medical Management:

• Patient already on aspirin 81mg daily, continue
• Already on clopidogrel 75mg daily, continue (no additional loading given chronic use)
• Heparin infusion initiated at reduced dose (given renal function): 60 units/kg bolus (4000 units) followed by 10 units/kg/hr infusion, adjust per PTT
• Hold metoprolol given bradycardia (HR 58) and relative hypotension (BP 102/58)
• Continue atorvastatin 40mg nightly
• Continue lisinopril 10mg daily, monitor BP closely
• Hold metformin in anticipation of cardiac catheterization (contrast-induced nephropathy risk)

Cardiology Consultation: Cardiology consulted, Dr. Martinez evaluated patient at 3:30 PM. Agrees with NSTEMI diagnosis. Given high-risk features, recommend cardiac catheterization tomorrow AM (early invasive approach) rather than urgent tonight given hemodynamic stability. Plan for coronary angiography at 8 AM with potential for PCI.

Renal Protection: Pre-catheterization hydration protocol initiated: NS at 75 mL/hr x12 hours before and 12 hours after procedure (adjusted rate for elderly patient and CKD)

Admission Orders:

• Admit to Cardiac Care Unit for continuous telemetry monitoring
• Serial troponins: baseline, 3 hours, 6 hours to establish peak
• Strict bed rest for now
• Cardiac diet, diabetic (consistent carb)
• NPO after midnight for morning catheterization
• Check PTT 6 hours after heparin initiation, target 50-70 seconds
• Serial BMP to monitor renal function and electrolytes
• Continuous pulse oximetry, supplemental O2 to maintain sat greater than 92%

Risk Factor Management:

• Diabetes management: insulin sliding scale given holding metformin, endocrine consult if needed
• Blood pressure management: monitor closely, may need to adjust medications post-catheterization

Patient/Family Communication: Extensive discussion with patient and daughter regarding diagnosis of heart attack, need for cardiac catheterization to evaluate coronary arteries and determine if additional stenting needed. Reviewed risks including bleeding, kidney injury (given pre-existing CKD), stroke, need for bypass surgery, and death. Also discussed risks of NOT pursuing catheterization given high-risk presentation. Patient and daughter expressed understanding and agreement with plan. Patient stated she wants "everything done."

Follow-Up:

• Coronary angiography scheduled 8 AM tomorrow (12/31)
• Further management based on catheterization findings
• If PCI performed, continue DAPT minimum 12 months
• Cardiac rehabilitation referral post-discharge
• Close follow-up with cardiology within 1 week of discharge
• Nephrology follow-up for CKD management

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