Complete Guide to Myocardial Infarction SOAP Note Examples for Healthcare Providers

If you've ever struggled to document MI cases in a way that captures the urgency while meeting insurance and medicolegal requirements, this guide is for you.

I've talked to countless emergency physicians, cardiologists, hospitalists, and intensivists who know that MI documentation isn't just about satisfying insurance—it's about creating a defensible medical record for one of the highest-risk conditions in medicine.

The reality is that myocardial infarction documentation has specific requirements that go far beyond routine notes.

Insurance companies and legal reviewers want to see clear timelines, appropriate risk stratification, evidence of guideline-based care, documentation of door-to-balloon times, and proof that critical interventions happened promptly.

That's exactly why I built SOAP Notes Doctor to handle the documentation burden while you focus on saving lives.

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

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

SOAP notes might feel like an afterthought when you're managing an acute MI, but they serve a critical purpose.

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 myocardial infarction specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of presentation time, symptom onset, and door-to-intervention times
• Appropriate risk stratification using validated scores (TIMI, GRACE)
• Evidence of guideline-directed therapy and timely interventions
• Medical necessity for procedures, ICU admission, and advanced therapies
• Proper follow-up planning and secondary prevention strategies
• A defensible timeline if medicolegal review occurs

SOAP stands for:

• S — Subjective: What the patient reports about chest pain characteristics, associated symptoms, time of onset, and risk factors.
• O — Objective: Your clinical findings including vitals, EKG findings, cardiac biomarkers, imaging results, and catheterization findings.
• A — Assessment: Your clinical diagnosis with MI classification (STEMI vs NSTEMI), risk stratification, complications, and severity assessment.
• P — Plan: Your treatment plan including reperfusion strategy, medications, interventions, monitoring, and disposition.

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 emergent care and documents appropriate decision-making.

How You Can Approach MI SOAP Notes

There's no single correct method for writing MI 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 stabilizing the patient. It works if you have strong clinical writing skills and can document while managing the case. The challenge is that during an acute MI, you're focused on time-critical interventions, not documentation. Notes often get completed hours later when details are less fresh.

2. SOAP Notes Doctor

You record key findings and timeline elements during or immediately after the case, and the tool automatically structures everything into proper SOAP format. It maintains consistency, ensures you don't miss critical medicolegal elements, and saves hours of documentation time—letting you focus on the next patient.

How to Make MI SOAP Notes Faster

One of the biggest challenges with MI documentation is capturing everything that happened in a time-critical situation.

You've just managed an acute STEMI, coordinated with the cath lab, initiated appropriate medications, and stabilized the patient—and now you need to document every detail with precise timing for insurance and medicolegal protection.

The pressure is real: miss critical elements like door-to-EKG time or medication administration times, and you risk liability issues; make notes too verbose and you've just added an hour to your shift.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record key findings and timeline elements
✅ Generate properly formatted SOAP notes instantly
✅ Get complete, defensible documentation without the time burden

With soapnotes.doctor, you can quickly capture the essential elements during the case or immediately after, and the system converts everything into comprehensive, insurance-compliant SOAP notes automatically.

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

Maybe you noted specific findings?

"Onset 0630, arrival ED 0715, EKG 0718 shows 3mm STE inferior leads, troponin 2.4, cath lab activated 0722, door-to-balloon 67 minutes, 100% RCA occlusion, successful PCI with DES."

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

Example 1: Acute STEMI with Primary PCI

Patient: 58-year-old male
Chief Complaint: Severe chest pain
Visit: Emergency Department, acute STEMI

S – Subjective:

Patient presented to ED via EMS with acute onset severe substernal chest pain. Pain began at approximately 0630 this morning while mowing lawn, described as "crushing pressure, like an elephant sitting on my chest," 10/10 severity. Radiates to left arm and jaw. Associated with diaphoresis, nausea, and shortness of breath. No relief with rest. Took aspirin 325mg given by EMS. Denies prior episodes of similar pain. Medical history: hypertension (controlled on lisinopril 20mg daily), hyperlipidemia (on atorvastatin 40mg daily), no diabetes. Surgical history: appendectomy age 22. Family history: father had MI at age 62, mother with hypertension. Social history: 30 pack-year smoking history (currently smokes 1 PPD), rare alcohol use, denies illicit drug use. Medications: lisinopril 20mg daily, atorvastatin 40mg daily, aspirin 81mg daily. Allergies: NKDA. Last meal 0600 (toast and coffee).

O – Objective:

Timeline:

• Symptom onset: 0630
• EMS arrival to patient: 0645
• EMS arrival to ED: 0715
• Door-to-EKG: 3 minutes (0718)
• Cardiology notification: 0722
• Cath lab activation: 0722
• Door-to-balloon time: 67 minutes (0822)

Initial Vital Signs (0715): BP 168/94, HR 102, RR 22, O2 sat 94% on RA, Temperature 98.2°F

Physical Examination: General: Anxious-appearing male, diaphoretic, in moderate distress
HEENT: Normocephalic, atraumatic, pupils equal and reactive
Cardiovascular: Tachycardic, regular rhythm, no murmurs, rubs, or gallops appreciated, no JVD
Pulmonary: Tachypneic, clear to auscultation bilaterally, no rales or wheezes
Abdomen: Soft, non-tender, non-distended, normal bowel sounds
Extremities: No edema, peripheral pulses intact, cool extremities, capillary refill 3 seconds
Neurological: Alert and oriented x3, no focal deficits

Diagnostics: EKG (0718): Sinus tachycardia at 102 bpm, 3-4mm ST-segment elevation in leads II, III, aVF; reciprocal ST depression in leads I, aVL; concerning for acute inferior STEMI

Laboratory Results (0720):

• Troponin I: 2.4 ng/mL (elevated, consistent with acute MI)
• CK-MB: 45 ng/mL (elevated)
• CBC: WBC 12.3, Hgb 14.8, Platelets 256
• BMP: Na 138, K 4.1, Cr 1.0, Glucose 156
• Coagulation: PT 12.1, INR 1.0, PTT 28

Chest X-Ray (portable, 0725): No acute cardiopulmonary process, normal cardiac silhouette, no pulmonary edema

Cardiac Catheterization (0822-0935):

• Right dominant system
• Left main: no significant disease
• LAD: 40% mid-vessel stenosis, non-obstructive
• LCx: mild luminal irregularities, non-obstructive
• RCA: 100% acute thrombotic occlusion proximal segment
• Successful PCI to proximal RCA with drug-eluting stent (3.0 x 18mm), TIMI 3 flow restored
• No residual stenosis
• LV gram: moderate hypokinesis of inferior wall, estimated EF 45%

A – Assessment:

58-year-old male with acute ST-elevation myocardial infarction (STEMI), inferior wall distribution, due to acute thrombotic occlusion of proximal right coronary artery. Successfully treated with primary percutaneous coronary intervention (PCI) with drug-eluting stent placement, TIMI 3 flow achieved. Door-to-balloon time 67 minutes (within guideline-recommended 90 minutes). Killip Class I on presentation (no signs of heart failure). TIMI Risk Score 3 (intermediate risk). Complications: none during procedure. Left ventricular systolic function moderately reduced (EF 45%) due to acute infarction. Patient hemodynamically stable post-procedure.

P – Plan:

Immediate Post-Procedure Management:

• Transfer to Coronary Care Unit for continuous cardiac monitoring
• Hemodynamic monitoring with arterial line initially, telemetry ongoing
• Serial troponins every 6 hours x3 to assess peak
• Repeat EKG in AM and with any recurrent chest pain
• Strict bed rest for 6 hours post-procedure (femoral access), then gradual mobilization
• NPO until confirmed no complications, then cardiac diet
• Vascular access site monitoring every 15 minutes x4, then every 30 minutes x4, then hourly

Medications Initiated:

• Aspirin 325mg loading dose (given by EMS), then 81mg daily indefinitely
• Ticagrelor 180mg loading dose given pre-cath, then 90mg BID for 12 months (dual antiplatelet therapy)
• Atorvastatin increased to 80mg daily (high-intensity statin)
• Metoprolol tartrate 25mg BID (titrate to HR 50-60)
• Lisinopril 20mg daily continued (ACE inhibitor for LV dysfunction)
• Unfractionated heparin infusion during procedure, discontinued post-PCI
• Nitroglycerin 0.4mg SL PRN for chest pain (patient education provided)

Cardiac Rehabilitation: Referral placed for outpatient cardiac rehabilitation program, to begin 2-4 weeks post-discharge

Secondary Prevention Counseling:

• Smoking cessation counseling provided, prescribed nicotine replacement therapy, referral to cessation program
• Discussed importance of medication adherence, especially dual antiplatelet therapy
• Dietary counseling: low sodium, heart-healthy diet, referral to dietitian
• Stress reduction and gradual return to activity

Risk Factor Modification:

• HgbA1c ordered to screen for diabetes (elevated admission glucose)
• Lipid panel to recheck in 4-6 weeks, goal LDL less than 70 mg/dL
• Blood pressure management, goal less than 130/80

Echocardiogram: Scheduled for tomorrow AM to formally assess LV function, wall motion abnormalities, and rule out mechanical complications

Follow-Up:

• Cardiology follow-up in 1 week post-discharge
• Primary care follow-up in 2 weeks for risk factor management
• Repeat stress test in 6-8 weeks if stable

Discharge Planning: Anticipated discharge in 3-4 days if no complications, stable hemodynamics, and successful mobilization

Patient and family educated on diagnosis, treatment, medications, warning signs of complications (recurrent chest pain, shortness of breath, bleeding from access site), and importance of medication adherence and lifestyle modifications. Patient verbalized understanding and expressed motivation for recovery and risk factor modification.

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Example 2: NSTEMI with Medical Management

Patient: 72-year-old female
Chief Complaint: Chest discomfort and shortness of breath
Visit: Hospital admission via ED, NSTEMI

S – Subjective:

Patient presented to ED with 6-hour history of intermittent substernal chest discomfort, described as "tightness and pressure," 6/10 severity, occurring at rest. Associated with dyspnea and mild nausea. Symptoms began around 1400 today while watching television. Initially attributed to indigestion, took antacids without relief. Came to ED when symptoms persisted and worsened. Denies radiation, diaphoresis at onset (though now appears diaphoretic). No prior cardiac history but reports "borderline high blood pressure" never treated. Medical history: type 2 diabetes mellitus (on metformin), chronic kidney disease stage 3 (baseline creatinine 1.6), osteoarthritis. Surgical history: hysterectomy age 48. Family history: mother and sister with coronary artery disease. Social history: never smoker, no alcohol. Medications: metformin 1000mg BID, ibuprofen PRN for arthritis. Allergies: sulfa drugs (rash).

O – Objective:

Vital Signs (ED arrival 2015): BP 156/88, HR 94, RR 20, O2 sat 92% on RA (96% on 2L NC), Temperature 98.4°F

Physical Examination: General: Elderly female, appears anxious, mildly diaphoretic
Cardiovascular: Regular rate and rhythm, S4 gallop present, no murmurs, JVD not elevated
Pulmonary: Bilateral basilar crackles, no wheezes
Abdomen: Soft, non-tender, obese
Extremities: No edema, pedal pulses diminished bilaterally
Neurological: Alert and oriented x3, no deficits

EKG (2020): Sinus rhythm at 94 bpm, 1-2mm ST-segment depression in leads V4-V6, T-wave inversions in leads I, aVL, V5-V6; no ST elevation

Laboratory Results:

• Troponin I: 0.8 ng/mL at presentation (2020), 3.2 ng/mL at 6 hours (0220), 5.1 ng/mL at 12 hours (0820)—rising pattern consistent with acute MI
• CK-MB: 28 ng/mL, rising
• BNP: 420 pg/mL (elevated, suggests some cardiac dysfunction)
• CBC: WBC 9.8, Hgb 11.2 (mild anemia), Platelets 198
• BMP: Na 136, K 4.4, Cr 1.8 (elevated from baseline 1.6), eGFR 32, Glucose 198
• HgbA1c: 8.2% (poorly controlled diabetes)
• Lipid panel: Total cholesterol 245, LDL 165, HDL 38, Triglycerides 210

Chest X-Ray: Mild pulmonary vascular congestion, small bilateral pleural effusions, cardiomegaly

Echocardiogram (hospital day 1): LV ejection fraction 40-45%, mild LV hypertrophy, hypokinesis of anterolateral wall, grade 2 diastolic dysfunction, trace mitral regurgitation, no pericardial effusion

A – Assessment:

72-year-old female with acute non-ST-elevation myocardial infarction (NSTEMI) based on rising cardiac biomarkers and ischemic EKG changes. GRACE risk score 145 (high risk). TIMI Risk Score for UA/NSTEMI: 5 (high risk). Complicated by acute decompensated heart failure (ADHF) with pulmonary edema, likely due to acute ischemia and underlying diastolic dysfunction. Newly reduced LV systolic function (EF 40-45%). Multiple cardiovascular risk factors including diabetes, hypertension, hyperlipidemia, chronic kidney disease, obesity. AKI on CKD (creatinine 1.8, elevated from baseline 1.6), likely prerenal in setting of poor forward flow. Given high-risk features, patient is candidate for invasive strategy with cardiac catheterization; however, significant CKD and elevated creatinine increase contrast-induced nephropathy risk. Cardiology consulted.

P – Plan:

Acute Management:

• Admit to Cardiac Telemetry Unit, continuous monitoring
• Oxygen therapy to maintain O2 sat greater than 92%
• Serial troponins every 6 hours until peak, then daily
• Daily EKGs and with any symptom recurrence

Medical Therapy (Ischemic Protocol):

• Aspirin 325mg loading dose given, then 81mg daily
• Ticagrelor 180mg loading dose, then 90mg BID (consideration of clopidogrel deferred given higher bleeding risk with renal dysfunction)
• Atorvastatin 80mg daily (high-intensity statin)
• Metoprolol tartrate 25mg BID, titrate to HR 50-60 and SBP greater than 100
• Lisinopril 5mg daily (low dose given renal dysfunction)
• Unfractionated heparin infusion (renally adjusted) for anticoagulation
• Nitroglycerin SL 0.4mg PRN chest pain

Heart Failure Management:

• Furosemide 20mg IV BID for diuresis (gentle given renal dysfunction)
• Strict I&O monitoring, daily weights, fluid restriction 1.5L daily
• Low-sodium cardiac diet

Renal Protection:

• Hold metformin given AKI and potential for catheterization
• IV fluids NS at 75 mL/hr for renal protection pre-catheterization
• Renal dosing of all medications
• Consult nephrology for co-management of CKD and potential catheterization

Invasive Strategy:

• Cardiology recommends cardiac catheterization within 24-48 hours given high-risk features (rising troponins, dynamic EKG changes, reduced EF, GRACE score 145)
• Contrast-induced nephropathy risk discussed with patient and family
• Pre-catheterization hydration protocol initiated
• N-acetylcysteine 600mg PO BID x4 doses for renal protection
• Plan for possible PCI vs CABG depending on anatomy

Diabetes Management:

• Insulin sliding scale initiated (metformin held)
• Endocrine consult for diabetes optimization post-discharge

Patient Education: Discussed diagnosis, treatment plan, medications, and potential need for catheterization and revascularization. Explained risks and benefits of invasive approach given renal dysfunction. Patient and family verbalized understanding and consented to planned catheterization.

Anticipated Course: Plan for catheterization on hospital day 2, possible discharge hospital day 4-5 if uncomplicated course, with close cardiology and nephrology follow-up.

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Example 3: Post-MI Follow-Up in Cardiology Clinic

Patient: 58-year-old male (same patient from Example 1, 6 weeks post-STEMI)
Chief Complaint: Follow-up after myocardial infarction
Visit: Outpatient cardiology follow-up

S – Subjective:

Patient returns for follow-up 6 weeks after inferior STEMI with successful primary PCI to RCA. Reports doing well overall with gradual improvement in exercise tolerance. Completed phase 1 cardiac rehabilitation in hospital and has attended 8 sessions of outpatient cardiac rehab with good tolerance. Currently walking 30 minutes daily without chest pain or significant dyspnea. Denies recurrent chest pain, pressure, or anginal equivalents. No palpitations, syncope, or presyncope. Denies orthopnea, PND, or lower extremity edema. Medication compliance excellent, taking all medications as prescribed. Successfully quit smoking 6 weeks ago (day of MI), using nicotine patches with good effect. No cravings in past 2 weeks. Following cardiac diet with wife's assistance, reports adherence to low sodium and heart-healthy eating. Energy level improved, has returned to light activities and desk work (accountant). Some anxiety about returning to full activities and fear of recurrent event.

O – Objective:

Vital Signs: BP 118/72, HR 58, Weight 188 lbs (down 12 lbs from admission weight), BMI 27.2

Physical Examination: General: Well-appearing male, no acute distress
Cardiovascular: Bradycardic, regular rhythm, normal S1/S2, no murmurs, rubs, or gallops, JVD not elevated, PMI not displaced
Pulmonary: Clear to auscultation bilaterally, no crackles or wheezes
Extremities: No edema, peripheral pulses intact bilaterally, no bruits
Neurological: Alert, oriented, appropriate

EKG (in clinic today): Sinus bradycardia at 58 bpm, Q waves in leads II, III, aVF (consistent with prior inferior MI), no acute ST-T changes, PR interval normal, QRS normal duration

Recent Labs (drawn 1 week ago):

• Lipid panel: Total cholesterol 142, LDL 68 (at goal less than 70), HDL 42, Triglycerides 160
• BMP: All within normal limits, Cr 1.0
• HgbA1c: 5.4% (non-diabetic range)
• CBC: Within normal limits

Echocardiogram (4 weeks post-MI): LV ejection fraction improved to 50% (was 45% immediately post-MI), mild residual hypokinesis of inferior wall, no significant valvular disease, no LV thrombus

Exercise Stress Test (performed last week at cardiac rehab): Bruce protocol, 8 minutes 30 seconds, 9.2 METs achieved, target heart rate achieved, no chest pain, no significant ST changes, no arrhythmias, good functional capacity, negative for ischemia

A – Assessment:

58-year-old male 6 weeks status post inferior STEMI with successful PCI to RCA, recovering well. Excellent medication adherence and lifestyle modification including smoking cessation, dietary changes, and participation in cardiac rehabilitation. LV function improved from 45% to 50% on repeat echocardiogram. Recent negative stress test suggests adequate revascularization without residual ischemia. Lipid panel at goal on high-intensity statin. Blood pressure well-controlled on current regimen. HR appropriately reduced on beta-blocker. No signs or symptoms of heart failure. Mild anxiety about cardiac event, which is normal, but patient engaging in appropriate activities and gradual return to function. Overall prognosis good given successful revascularization, excellent risk factor modification, and patient engagement in recovery.

P – Plan:

Medications:

• Continue aspirin 81mg daily indefinitely
• Continue ticagrelor 90mg BID—to complete 12 months of dual antiplatelet therapy (6 more months remaining), then discontinue and continue aspirin alone
• Continue atorvastatin 80mg daily, LDL at goal
• Continue metoprolol succinate 50mg BID (converted from tartrate), HR well-controlled
• Continue lisinopril 20mg daily, BP at goal

Cardiac Rehabilitation: Encourage continued participation in phase 2 cardiac rehab, goal of 36 sessions. Progress to independent exercise program afterward with goal of 150 minutes moderate-intensity activity weekly.

Lifestyle Modifications:

• Praised patient for smoking cessation, discussed plan to taper off nicotine patches over next month
• Continue cardiac diet, maintain weight loss
• Encouraged stress management techniques given mild anxiety

Monitoring:

• Repeat lipid panel in 6 months to ensure maintained control
• Annual stress test to reassess functional capacity and screen for ischemia
• Next echocardiogram in 1 year unless clinically indicated sooner

Return to Work: Cleared to return to full-time work as accountant (sedentary job). Advised gradual increase in work hours if desired. Discussed appropriate physical activity limits and warning signs requiring cessation of activity.

Psychological Support: Given mild anxiety about recurrent events, provided reassurance based on objective testing showing good recovery. Offered referral to cardiac psychology if anxiety worsens or interferes with function. Patient declined at this time but appreciates option.

Follow-Up: Return to cardiology clinic in 6 months unless any concerns arise sooner. Instructed to call immediately or present to ED if experiences recurrent chest pain, dyspnea, palpitations, or other concerning symptoms. Patient verbalized understanding and expressed satisfaction with recovery progress.

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Key Components Insurance Companies Look For in MI SOAP Notes

When reviewing your myocardial infarction documentation, insurance companies and medicolegal reviewers specifically want to see:

1. Timeline Documentation

Document symptom onset time, arrival time, EKG time, door-to-balloon time for STEMI, or time to catheterization decision for NSTEMI. These metrics demonstrate quality care.

2. STEMI vs NSTEMI Classification

Clear differentiation based on EKG findings and clinical presentation. This drives treatment algorithms and justifies interventions.

3. Risk Stratification

Use validated scores (TIMI, GRACE, Killip classification). These justify level of care, ICU admission, and invasive strategies.

4. Guideline-Directed Therapy

Document administration of aspirin, P2Y12 inhibitor, anticoagulation, beta-blocker, ACE inhibitor/ARB, and high-intensity statin with timing and doses.

5. Reperfusion Strategy

For STEMI, document primary PCI vs fibrinolysis decision with rationale. For NSTEMI, document early invasive vs conservative approach with risk-benefit analysis.

6. Procedural Details

Document catheterization findings, interventions performed, complications, and outcomes. This justifies procedural costs.

7. Complication Screening

Document assessment for cardiogenic shock, arrhythmias, mechanical complications, heart failure, and bleeding.

8. Secondary Prevention

Document smoking cessation counseling, cardiac rehab referral, lipid management, and patient education.

Common Mistakes to Avoid

Missing Timeline Elements: Always document symptom onset, arrival time, EKG time, and intervention times. Door-to-balloon time is a core quality metric.

Vague Chest Pain Description: Document OPQRST characteristics: Onset, Provocation, Quality, Radiation, Severity, Timing. This differentiates cardiac from non-cardiac pain.

Incomplete EKG Interpretation: Document specific leads with ST changes, degree of elevation/depression, and presence of reciprocal changes or Q waves.

No Risk Score Documentation: Use TIMI or GRACE scores. Insurance increasingly requires standardized risk assessment for NSTEMI management decisions.

Missing Medication Timing: Document when aspirin, heparin, and P2Y12 inhibitors were given. Timing affects outcomes and is scrutinized in quality reviews.

Inadequate Complication Assessment: Screen for and document presence or absence of heart failure, cardiogenic shock, arrhythmias, and mechanical complications.

No Secondary Prevention Documentation: Insurance wants proof of smoking cessation counseling, cardiac rehab referral, lipid management, and medication education.

Forgetting Troponin Trends: Document serial troponin values. Rising pattern confirms MI diagnosis and influences treatment decisions.

Final Thoughts

Myocardial infarction SOAP notes don't need to be overwhelming, even in time-critical situations.

They need to be thorough, yes, but they don't need to consume your life or delay patient care.

The key is having a system that captures the right information without interfering with clinical management.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that demonstrates appropriate care, meets insurance requirements, and protects you medicolegally.

Your time is better spent managing acute patients and optimizing outcomes 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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