The 2026 Guide to Peripheral Artery Disease SOAP Note Examples for Healthcare Providers

If you've ever struggled to document PAD visits in a way that justifies interventions while meeting insurance requirements, this guide is for you.

I've talked to countless vascular surgeons, cardiologists, and primary care physicians who spend hours documenting peripheral artery disease management, trying to justify revascularization procedures, medication therapies, and specialist referrals.

The reality is that peripheral artery disease documentation has specific requirements that insurance companies scrutinize heavily.

They want to see clear functional impairment, documented claudication distance, ankle-brachial index measurements, and evidence that conservative management has been attempted before approving invasive procedures.

That's exactly why I built SOAP Notes Doctor to handle the documentation burden while you focus on preventing limb loss and improving patient outcomes.

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

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

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose for vascular patients.

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 PAD specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of functional limitation and claudication symptoms
• Objective vascular assessment with ABI measurements and pulse examinations
• Evidence of conservative management before invasive procedures
• Medical necessity for revascularization, medications, or advanced imaging
• Risk factor modification and lifestyle intervention efforts

SOAP stands for:

• S — Subjective: What the patient reports about leg pain, walking distance, rest pain, lifestyle impact, and risk factor compliance.
• O — Objective: Your clinical findings including pulses, skin changes, ABI measurements, wound assessment, and vascular study results.
• A — Assessment: Your clinical diagnosis with Rutherford or Fontaine classification, severity assessment, and limb threat evaluation.
• P — Plan: Your treatment plan including medications, exercise therapy, risk factor modification, procedures, and follow-up testing.

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 ongoing management and interventions.

How You Can Approach PAD SOAP Notes

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

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

1. Traditional, Manual Documentation

This is the classic method: typing out each section after each visit. It works if you have strong clinical writing skills and consistent time built into your schedule. The challenge is it's time-consuming, and notes can become inconsistent, especially when documenting subtle changes in claudication distance or wound progression.

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 hours of documentation time, and ensures you never miss critical components that insurance companies look for in PAD management.

How to Make PAD SOAP Notes Faster

One of the biggest complaints I hear from providers managing vascular patients is how documentation eats into their already limited time.

You've just finished a full clinic seeing complex patients with multiple comorbidities, performing vascular assessments, and coordinating procedures, and instead of reviewing imaging studies or going home, you're stuck typing detailed notes for insurance.

The pressure is real: make them too brief and you risk denials for angiography or revascularization; make them too detailed and you've just added hours to your day.

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 your evenings and weekends back

With soapnotes.doctor, you can record during or right after a visit, 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?

"Diminished femoral pulse right, absent DP/PT pulses bilaterally, ABI 0.65 right 0.58 left, claudicates at 100 feet, no rest pain, skin cool and hairless lower legs."

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

Example 1: Initial PAD Evaluation with Claudication

Patient: 67-year-old male
Chief Complaint: Leg pain with walking
Visit: New patient evaluation

S – Subjective:

Patient reports bilateral leg cramping pain in calves when walking, occurring consistently after approximately 2 blocks (about 200 feet). Pain described as cramping and tightness, rated 6/10, relieved within 5 minutes of rest. Symptoms began 8 months ago, progressively worsening over time. Initially could walk 4-5 blocks before onset. Denies rest pain, ulcers, or color changes. No night pain. Symptoms significantly limit grocery shopping and household activities. Medical history significant for hypertension, type 2 diabetes, hyperlipidemia, and 40-pack-year smoking history (quit 5 years ago). Currently taking metformin, lisinopril, and atorvastatin. No previous vascular procedures.

O – Objective:

Vital Signs: BP 142/88, HR 76, BMI 28.4
Vascular Exam: Femoral pulses 2+ bilaterally, popliteal pulses 1+ bilaterally, dorsalis pedis and posterior tibial pulses absent bilaterally
Skin: Lower extremities cool to touch below knees, diminished hair growth, no rubor or pallor with elevation, capillary refill 4 seconds in toes
Extremities: No ulcers, no edema, toenails thickened
ABI: Right 0.62, Left 0.58 (consistent with moderate PAD)
Labs: HbA1c 7.8%, LDL 118 mg/dL, Creatinine 1.1 mg/dL

A – Assessment:

Moderate bilateral lower extremity peripheral artery disease with intermittent claudication, Rutherford Category 3. Claudication distance approximately 200 feet significantly impairs functional status and quality of life. Risk factors include diabetes, hypertension, hyperlipidemia, and former tobacco use. Currently meeting criteria for supervised exercise therapy and optimal medical management trial before considering revascularization.

P – Plan:

Initiate cilostazol 100mg BID for symptom management. Start supervised exercise therapy program, referral sent. Optimize medical management: increase atorvastatin to 80mg daily for intensive lipid lowering, continue diabetes and blood pressure management. Patient counseled on importance of smoking cessation maintenance and daily walking despite discomfort. Order arterial duplex ultrasound of lower extremities to further define disease extent and anatomy. Follow-up in 6 weeks to assess response to medical therapy and exercise program. If inadequate symptom improvement after 3 months of conservative management, will consider CT angiography and vascular surgery referral for revascularization evaluation.

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Example 2: Follow-Up Visit for Established PAD on Medical Management

Patient: 72-year-old female
Chief Complaint: Routine PAD follow-up
Visit: Established patient, 6-month check

S – Subjective:

Patient reports stable claudication symptoms. Continues to experience calf pain with walking approximately 3 blocks, unchanged from previous visits. Pain reliably relieved with rest. Denies rest pain, foot ulcers, or tissue loss. Compliant with walking program, averaging 20-30 minutes daily. Taking cilostazol and aspirin as prescribed. Blood pressure well-controlled at home. HbA1c improved with dietary modifications. Quit smoking 18 months ago, no relapses. Able to perform desired activities of daily living with symptom limitation but acceptable to patient.

O – Objective:

Vital Signs: BP 128/76, HR 68
Vascular Exam: Femoral pulses 2+ bilateral, popliteal 1+ bilateral, DP/PT pulses absent bilateral (unchanged)
Skin: No new ulcers, no tissue loss, appropriate temperature
Extremities: No edema, intact skin
ABI: Right 0.64, Left 0.61 (stable compared to 6 months ago)
Labs: HbA1c 6.9% (improved from 7.8%), LDL 82 mg/dL

A – Assessment:

Stable bilateral PAD with intermittent claudication on optimal medical management. Symptoms controlled and acceptable to patient. No disease progression based on stable ABI measurements and unchanged claudication distance. Risk factors well-managed with excellent patient compliance.

P – Plan:

Continue current medical regimen including cilostazol, aspirin, and statin therapy. Encourage continuation of daily walking program. Patient to monitor for any worsening symptoms including decreased walking distance, rest pain, or skin changes. Follow-up in 6 months with repeat ABI measurements. Patient instructed to call sooner if symptoms worsen or new concerns develop.

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Example 3: Critical Limb Ischemia Requiring Urgent Intervention

Patient: 78-year-old male
Chief Complaint: Right foot pain at rest and non-healing ulcer
Visit: Urgent vascular consultation

S – Subjective:

Patient reports severe right foot pain at rest for past 3 weeks, worse at night, partially relieved by dangling foot off bed. Pain rated 8/10, constant, burning quality. Notes non-healing ulcer on right great toe for 6 weeks, initially minor trauma that has not healed. Previously diagnosed with PAD 3 years ago, managed medically with intermittent claudication. Now unable to walk more than 50 feet due to pain. Denies fever or chills. History of diabetes, CAD with prior MI, hypertension, and current smoker (1 pack per day).

O – Objective:

Vital Signs: BP 156/92, HR 88, Temp 98.2°F
Vascular Exam: Femoral pulse 1+ right (diminished), popliteal absent right, DP/PT absent right, all pulses on left 1-2+
Skin: Right foot pale and cool, delayed capillary refill greater than 5 seconds, 1.5cm ulcer on right great toe with fibrinous base, minimal granulation, surrounding erythema, no purulent drainage
ABI: Right 0.42, Left 0.68
Labs: WBC 10.2, Creatinine 1.4, HbA1c 9.2%

A – Assessment:

Critical limb ischemia of right lower extremity, Rutherford Category 5 with minor tissue loss. Severe multilevel PAD based on absent distal pulses and markedly reduced ABI. Non-healing diabetic ulcer in setting of severe PAD. High risk for limb loss without revascularization. Patient meets criteria for urgent vascular imaging and intervention.

P – Plan:

Admit for IV pain control and urgent CT angiography to define vascular anatomy for revascularization planning. Vascular surgery consulted for urgent evaluation. Start IV antibiotics (vancomycin and ceftriaxone) given wound infection concerns. Wound care consult for specialized dressing and offloading. Aggressive glycemic control with insulin. Smoking cessation counseling initiated. Plan for angiography with possible angioplasty/stenting versus surgical bypass based on anatomy. Patient and family counseled on limb salvage versus amputation risks. Will proceed with revascularization attempt within 24-48 hours.

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Key Components Insurance Companies Look For in PAD SOAP Notes

When reviewing your peripheral artery disease documentation, insurance companies specifically want to see:

1. Functional Impairment Documentation

Specific claudication distance in feet or blocks, impact on activities of daily living, and Rutherford or Fontaine classification.

2. Objective Vascular Assessment

ABI measurements with specific values, pulse examination findings, and comparison to previous measurements showing stability or progression.

3. Conservative Management Attempts

Documentation of exercise therapy trial, medication management, and risk factor modification before approving invasive procedures.

4. Severity Classification

Clear documentation of intermittent claudication versus critical limb ischemia, presence of rest pain, tissue loss, or gangrene.

5. Risk Factor Management

Documentation of smoking cessation efforts, diabetes control, blood pressure management, and lipid therapy optimization.

6. Medical Necessity for Procedures

For revascularization approval, insurance wants evidence of lifestyle-limiting symptoms despite conservative therapy or critical limb ischemia.

Common Mistakes to Avoid

Vague Claudication Description: Instead of "leg pain with walking," document specific distance: "bilateral calf claudication after 150 feet, relieved with 3 minutes rest."

Missing ABI Values: Always document specific ABI measurements, not just "diminished" or "abnormal." Insurance requires objective numbers.

No Conservative Therapy Documentation: Before requesting revascularization approval, show you've tried medical management and exercise therapy for adequate duration.

Inadequate Pulse Examination: Document all peripheral pulses individually (femoral, popliteal, DP, PT) with grading scale.

No Rutherford Classification: This standardized classification helps insurance understand severity and medical necessity.

Forgetting Wound Documentation: For tissue loss, document ulcer size, location, appearance, and healing progress with each visit.

Final Thoughts

Peripheral artery disease SOAP notes don't need to be overwhelming.

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

The key is having a system that captures the right information without making you feel like a secretary instead of a clinician.

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 preventing limb loss and improving 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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Ready to simplify your PAD documentation?
Visit soapnotes.doctor and get your first notes generated in minutes.