How to Write SOAP Notes for Hyperlipidemia: Complete Guide with Examples

SOAP Note for Hyperlipidemia

It's 7 PM on a Thursday, you've seen 28 patients today, and you're staring at your inbox wondering how you're going to document all these lipid panel follow-ups before you can finally go home.

Your patient with hyperlipidemia came in for their 3-month statin check, and you need to justify continued therapy, document ASCVD risk, and show you counseled them on lifestyle modifications—all while making sure insurance doesn't flag the note as insufficient.

Sound familiar? If you've ever felt buried under cardiovascular risk documentation, keep reading.

We've all been there.

Quick Tip:

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

You can let it listen during your patient visit and do the work for you.

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

Head over to soapnotes.doctor now.

Let's dive in.

SOAP Notes: The Origin Story

Back in the 1960s, medical documentation was chaos.

One doctor might write "cholesterol high, gave medication" while another would produce a five-page dissertation on lipid metabolism. Nobody could make sense of anyone else's notes.

Then Dr. Lawrence Weed came along and said, "This is ridiculous. We need a system."

He created the Problem-Oriented Medical Record with SOAP notes at its core. His idea was brilliant in its simplicity: give everyone the same structure so any provider could pick up a chart and know exactly what's going on.

Here's what he came up with:

• S (Subjective): What the patient tells you about their symptoms, lifestyle, medication adherence
• O (Objective): What you measure and observe—vitals, labs, physical exam findings
• A (Assessment): Your clinical judgment about their cardiovascular risk and disease status
• P (Plan): What you're doing next—medication adjustments, lifestyle counseling, follow-up timing

This format spread like wildfire because it actually worked. Soon it was everywhere—hospitals, clinics, cardiology practices, and primary care offices managing millions of patients with hyperlipidemia.

How to Approach SOAP Notes for Hyperlipidemia: My Take

When I first started helping providers with documentation, I noticed something interesting.

The providers who struggled most weren't the ones who didn't know medicine—they knew their stuff. They struggled because they were trying to write "perfect" notes instead of useful ones.

Here's the truth I learned: "Document what matters, not what impresses."

Your note needs to show you assessed cardiovascular risk, justified treatment decisions, and counseled the patient. That's it. Everything else is extra.

There are two main ways you can handle hyperlipidemia SOAP notes:

Use soapnotes.doctor

I'm biased here because I built it, but there's a reason.

Hyperlipidemia notes have specific elements insurance companies look for: ASCVD risk calculation, statin intensity justification, lifestyle modification documentation, and lab trend analysis.

Miss any of these and you risk prior authorization denials or quality metric failures.

Here's how to streamline it:

1. Head over to soapnotes.doctor and complete onboarding if you're new.

2. During or right after the visit, record your key findings: "LDL 158, up from 142 three months ago. Patient admits not taking statin consistently due to muscle aches. ASCVD risk 12%. Discussed statin side effects and switched to rosuvastatin."

3. Wait 1-3 minutes for processing.

4. Review the generated note—it'll include proper risk stratification, medication justification, and counseling documentation automatically.

5. Use the tailor feature to add any specific details, then copy to your EHR.

The tool ensures you never miss the components that trigger insurance denials or quality measure failures.

Write Manually

Maybe you're old school or just want to flex your documentation muscles. That's cool too.

Here's what you need to nail in each section:

1. S - Subjective

This is where you capture what the patient tells you about their cardiovascular health and risk factors.

Purpose: Document the patient's perspective on symptoms, lifestyle, medication adherence, and concerns.

What to include:

• Medication adherence and any side effects
• Dietary habits and exercise patterns
• Family history of cardiovascular disease
• Smoking status and alcohol use
• Any chest pain, shortness of breath, or cardiovascular symptoms
• Patient's understanding of their condition and treatment goals

Examples:

"Patient reports taking atorvastatin 40mg daily as prescribed for past 3 months. Denies muscle pain, weakness, or dark urine. States he has reduced red meat intake and walks 20 minutes daily 4-5 times weekly. No chest pain or shortness of breath. Quit smoking 2 years ago. Father had MI at age 58."

"Patient admits inconsistent statin use, taking medication 'only a few times a week' due to concern about side effects she read online. Diet unchanged, continues eating fast food 4-5 times weekly. Not currently exercising. Denies cardiovascular symptoms. Mother and maternal grandmother both had strokes."

2. O - Objective

This section is critical for hyperlipidemia because insurance companies specifically look for lab trends and cardiovascular risk assessment.

Purpose: Document measurable findings that justify treatment decisions.

What to include:

• Current vital signs, especially blood pressure
• Lipid panel results with comparison to previous values
• Other relevant labs (HbA1c if diabetic, liver function, CK if on statins)
• ASCVD risk score calculation
• Physical exam findings (especially if assessing for xanthomas or peripheral vascular disease)
• BMI

Examples:

"Vital Signs: BP 128/78, HR 72, BMI 28.3. General: Well-appearing, no acute distress. Cardiovascular: Regular rate and rhythm, no murmurs. Peripheral pulses 2+ bilaterally. Labs: Total cholesterol 245 mg/dL (previously 268), LDL 158 mg/dL (previously 180), HDL 42 mg/dL, Triglycerides 180 mg/dL. AST 28, ALT 32 (within normal limits). 10-year ASCVD risk: 12.4% (intermediate risk)."

"Vital Signs: BP 142/88, HR 78, BMI 31.2. Cardiovascular: Regular rate and rhythm. Labs: Total cholesterol 285 mg/dL (baseline before starting therapy), LDL 198 mg/dL, HDL 38 mg/dL, Triglycerides 245 mg/dL. HbA1c 6.8% (patient has prediabetes). Baseline ALT 24, AST 22. 10-year ASCVD risk: 18.6% (high risk)."

3. A - Assessment

This is where you show your clinical reasoning and justify your treatment plan.

Purpose: Connect the subjective and objective findings to demonstrate why your treatment decisions are medically necessary.

What to include:

• Current cardiovascular risk category (low, borderline, intermediate, high)
• Response to current therapy (if on treatment)
• Contributing factors (medication adherence, lifestyle, genetics)
• Statin benefit group justification
• Any changes in risk profile

Examples:

"58-year-old male with hyperlipidemia on moderate-intensity statin therapy showing partial response. LDL decreased from 180 to 158 mg/dL but remains above goal of less than100 mg/dL for intermediate-risk patient (10-year ASCVD risk 12.4%). Patient adherent to medication with good tolerance. Lifestyle modifications showing improvement with documented dietary changes and increased physical activity. No diabetes or known ASCVD. Qualifies for continued statin therapy per ACC/AHA guidelines as intermediate-risk primary prevention."

"62-year-old female with uncontrolled hyperlipidemia, suboptimal medication adherence due to misconceptions about statin safety. LDL 198 mg/dL well above goal. High 10-year ASCVD risk of 18.6% places patient in high-risk category warranting high-intensity statin therapy. Multiple risk factors including prediabetes, low HDL, elevated triglycerides, and elevated blood pressure. Strong family history of premature cardiovascular disease. Patient would benefit significantly from risk reduction therapy but requires education to improve adherence."

4. P - Plan

Keep this section actionable and specific. Insurance companies want to see you're following guidelines and counseling patients appropriately.

Purpose: Outline clear next steps for risk reduction and continued management.

What to include:

• Specific medication plan (continue, adjust dose, or change medication)
• Lifestyle modification counseling documented
• Follow-up lab timing and what you're monitoring
• When patient should return
• Any referrals needed

Examples:

"Increase atorvastatin from 40mg to 80mg daily to achieve LDL goal less than100 mg/dL (high-intensity statin indicated for intermediate-risk patient not at goal). Patient counseled on importance of consistent medication adherence. Reinforced heart-healthy diet (Mediterranean diet recommended) and encouraged increasing exercise to 150 minutes weekly. Repeat lipid panel and hepatic function panel in 8 weeks to assess response and monitor for liver enzyme elevation. Follow-up appointment in 3 months. Patient verbalized understanding and agreement with plan."

"Prescribed rosuvastatin 20mg daily (high-intensity statin) for high-risk primary prevention. Extensive patient education provided regarding statin safety profile, benefits outweighing minimal risks, and importance of cardiovascular risk reduction given 18.6% 10-year risk. Discussed lifestyle modifications including dietary changes (reduce saturated fat, increase fiber), weight loss goal of 10%, and initiation of regular physical activity. Provided referral to dietitian for medical nutrition therapy. Baseline CK ordered due to planned statin initiation. Repeat lipid panel in 12 weeks with goal LDL less than100 mg/dL (ideally less than70 mg/dL given high risk). Blood pressure management plan discussed. Follow-up in 6 weeks to assess statin tolerance and reinforce lifestyle changes."

Complete SOAP Note Examples for Hyperlipidemia

Let's look at three complete examples that show different clinical scenarios you'll encounter.

Example 1: New Diagnosis of Hyperlipidemia

Patient: 52-year-old male
Visit Type: Follow-up for lipid panel results
Issue: Newly diagnosed hyperlipidemia

S – Subjective:

Patient returns to review lipid panel results drawn 1 week ago as part of routine health maintenance. Denies any chest pain, shortness of breath, palpitations, or exertional symptoms. Reports he generally feels healthy. Diet consists of "typical American food" with frequent red meat consumption and eating out 3-4 times weekly. Minimal physical activity, works desk job and "doesn't have time to exercise." Never smoked cigarettes. Drinks 2-3 beers on weekends. Family history significant for father who had heart attack at age 62, father underwent stent placement and is alive. Mother has diabetes. Patient reports he assumed his cholesterol was "probably fine" since he feels well. Expresses some concern now that labs are abnormal.

O – Objective:

Vital Signs: BP 136/84, HR 76, Weight 198 lbs, Height 5'10", BMI 28.4
General: Well-appearing, alert, in no distress
Cardiovascular: Regular rate and rhythm, normal S1/S2, no murmurs or gallops, peripheral pulses 2+ and symmetric bilaterally
Labs: Fasting lipid panel: Total cholesterol 268 mg/dL, LDL cholesterol 182 mg/dL, HDL cholesterol 38 mg/dL, Triglycerides 240 mg/dL
Additional labs: HbA1c 5.4% (normal), TSH 2.1 mIU/L (normal), Baseline ALT 32 U/L, AST 28 U/L (normal)
10-year ASCVD Risk Score: 11.8% (intermediate risk based on age, sex, total cholesterol, HDL, systolic BP, no diabetes, no smoking)

A – Assessment:

52-year-old male with newly diagnosed hyperlipidemia. LDL of 182 mg/dL significantly elevated with low HDL of 38 mg/dL and elevated triglycerides of 240 mg/dL, consistent with mixed dyslipidemia pattern. Patient has intermediate 10-year ASCVD risk of 11.8% warranting statin therapy for primary prevention per ACC/AHA guidelines. Multiple cardiovascular risk factors present including overweight BMI, prehypertension, physical inactivity, and strong family history of premature coronary artery disease. Secondary causes of hyperlipidemia ruled out (normal TSH, no diabetes). Patient has significant opportunity for risk reduction through both pharmacologic therapy and lifestyle modification. Strong candidate for moderate to high-intensity statin therapy.

P – Plan:

Initiated atorvastatin 40mg once daily in evening (moderate to high-intensity statin appropriate for intermediate-risk primary prevention with LDL greater than 160 mg/dL). Treatment goal LDL less than100 mg/dL, ideally less than70 mg/dL. Provided extensive counseling on hyperlipidemia as cardiovascular risk factor and benefits of treatment in reducing heart attack and stroke risk. Discussed lifestyle modifications as critical component of therapy: recommended heart-healthy diet (Mediterranean or DASH diet) with emphasis on reducing saturated fat, increasing fruits/vegetables/whole grains, limiting processed foods, and reducing portion sizes. Encouraged goal of 150 minutes weekly moderate-intensity aerobic activity. Weight loss goal of 5-10% (10-20 lbs). Addressed family history and importance of risk factor modification given paternal history. Ordered baseline CK given statin initiation. Instructed patient to report any unexplained muscle pain, weakness, or dark urine. Repeat lipid panel and hepatic function panel in 8-12 weeks to assess treatment response and monitor for adverse effects. Provided patient education materials on cholesterol management. Follow-up appointment scheduled in 3 months. Patient verbalized understanding of diagnosis, treatment rationale, and plan.

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Example 2: Statin Intolerance Requiring Medication Change

Patient: 67-year-old female
Visit Type: Established patient, problem visit
Issue: Muscle pain on current statin therapy

S – Subjective:

Patient presents with complaints of bilateral thigh and calf muscle pain that started approximately 2 weeks ago. Describes pain as "aching and sore" with severity 5-6/10, worse with walking or climbing stairs. States she has difficulty getting up from seated position. Denies muscle weakness or falls. No dark urine noted. Patient has been on simvastatin 40mg nightly for past 6 months for hyperlipidemia. Prior to this medication, LDL was 175 mg/dL. Patient reports she stopped taking simvastatin 3 days ago on her own because she suspected medication was causing symptoms, and notes slight improvement in pain since stopping. Denies any recent increase in physical activity or trauma. Currently takes lisinopril for hypertension and metformin for type 2 diabetes. Patient frustrated with muscle pain and states "I can't keep taking this medication if it makes me feel like this."

O – Objective:

Vital Signs: BP 132/76, HR 72, Weight 164 lbs, BMI 27.8
General: Alert, appears uncomfortable when standing from chair
Musculoskeletal: Mild tenderness to palpation of bilateral quadriceps and gastrocnemius muscles, no swelling or erythema, full range of motion, strength 5/5 in all extremities but patient reports pain with resistance
Cardiovascular: Regular rate and rhythm
Labs drawn today: CK 645 U/L (elevated, normal less than200), ALT 42 U/L (mild elevation, normal less than40), AST 38 U/L. Previous lipid panel from 4 months ago while on simvastatin: LDL 98 mg/dL, HDL 48 mg/dL, Total cholesterol 178 mg/dL, Triglycerides 160 mg/dL
10-year ASCVD Risk Score: 24.3% (high risk - diabetic patient over 65)

A – Assessment:

67-year-old female with history of hyperlipidemia and type 2 diabetes presenting with statin-associated muscle symptoms (SAMS). CK elevation to 645 U/L with myalgias temporally related to simvastatin use, with improvement after discontinuation, strongly suggests statin intolerance. Previous good LDL response to therapy (175 to 98 mg/dL) demonstrates efficacy before adverse effects developed. Patient is high cardiovascular risk given diabetes, age, and 10-year ASCVD risk greater than20%, making statin therapy essential for secondary prevention despite adverse effects. Options include switching to different statin at lower dose with better tolerability profile, alternative dosing schedule, or non-statin therapy. Given high cardiovascular risk, recommend trial of alternative statin rather than discontinuing lipid therapy entirely.

P – Plan:

Discontinue simvastatin permanently due to confirmed statin intolerance with elevated CK. Will trial rosuvastatin 5mg daily (lower dose of different statin with potentially better tolerance profile) after CK normalizes. Recheck CK in 1 week; if normalized (goal less than200), patient to start rosuvastatin. If CK remains elevated, will wait additional week before initiating. Discussed that not all statins cause same muscle effects and lower doses often better tolerated. Provided coenzyme Q10 100mg daily recommendation which may reduce muscle symptoms. If patient develops recurrent myalgias on rosuvastatin, will consider alternative strategies including every-other-day dosing or ezetimibe as non-statin option. Reinforced critical importance of lipid management given high cardiovascular risk from diabetes. Lifestyle modifications reviewed: heart-healthy diet, continue diabetes management, regular physical activity as tolerated. Repeat lipid panel 8 weeks after restarting statin therapy to ensure continued LDL control. Instructed patient to call immediately if develops severe muscle pain, weakness, or dark urine. Follow-up in 3 weeks to assess tolerance of new medication. Patient understands increased cardiovascular risk without lipid therapy and agrees to trial alternative statin.

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Example 3: Hyperlipidemia Follow-Up with Good Control

Patient: 61-year-old male with known ASCVD
Visit Type: Routine follow-up
Issue: Hyperlipidemia management, status post MI

S – Subjective:

Patient returns for routine cardiovascular follow-up. History of myocardial infarction 18 months ago, underwent PCI with stent placement to LAD. Currently on atorvastatin 80mg daily which he reports taking consistently without missing doses. Denies any muscle pain, weakness, or other side effects from medication. Reports excellent dietary compliance following cardiac rehabilitation program, has adopted Mediterranean diet and eliminated red meat. Exercises 5 days weekly with 40 minutes of walking or stationary bike. Lost 25 lbs since MI. Quit smoking 18 months ago and has remained tobacco-free. Takes all cardiac medications as prescribed including aspirin, clopidogrel, metoprolol, and lisinopril. Denies any chest pain, shortness of breath, palpitations, or concerning symptoms. Feels "the best I've felt in years." Motivated to continue current health regimen.

O – Objective:

Vital Signs: BP 118/72, HR 64, Weight 172 lbs (down from 197 at time of MI), BMI 24.9
General: Well-appearing, excellent spirits, no distress
Cardiovascular: Regular rate and rhythm, no murmurs, peripheral pulses intact bilaterally
Labs: Lipid panel: Total cholesterol 142 mg/dL, LDL cholesterol 58 mg/dL (goal less than70 achieved), HDL cholesterol 52 mg/dL, Triglycerides 132 mg/dL
Additional labs: ALT 28 U/L, AST 24 U/L (normal), HbA1c 5.3% (excellent), Creatinine 0.9 mg/dL
Comparison to pre-treatment values: Total cholesterol decreased from 248 to 142, LDL decreased from 168 to 58

A – Assessment:

61-year-old male with known ASCVD (prior MI with stent) demonstrating excellent secondary prevention with optimal lipid control. Current LDL of 58 mg/dL well below goal of less than70 mg/dL for secondary prevention, representing 65% reduction from baseline. Patient exemplifies successful cardiovascular risk factor modification through combination of high-intensity statin therapy, dramatic lifestyle changes, and sustained motivation. Excellent medication adherence without adverse effects. Significant weight loss and sustained tobacco cessation further reduce cardiovascular risk. No evidence of recurrent ischemia or statin-related adverse effects. This represents optimal management of hyperlipidemia in high-risk patient.

P – Plan:

Continue atorvastatin 80mg daily given excellent response and tolerance. Current regimen achieving guideline-recommended LDL goals for secondary prevention. Strongly encouraged patient to maintain current lifestyle modifications including Mediterranean diet, regular exercise, and tobacco abstinence as these provide additional cardiovascular benefit beyond medication. Praised patient's exceptional commitment to health improvement. Continue all cardiac medications as prescribed. Annual lipid panel adequate for patient with stable, well-controlled lipids on consistent therapy - next lipid panel in 12 months unless clinical change. Annual liver enzyme monitoring will continue. Follow-up with cardiology in 6 months per their recommendations. Follow-up with primary care in 6 months for routine management. Patient has excellent understanding of his condition and management plan. Encouraged to contact office with any concerning cardiac symptoms or if any questions arise. Discussed that continued adherence to medications and lifestyle is essential for maintaining low cardiovascular risk.

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Key Documentation Elements for Hyperlipidemia SOAP Notes

ASCVD Risk Calculation: Always include the 10-year risk percentage. This justifies treatment intensity and helps with prior authorizations.

Statin Intensity Justification: Document why you chose low, moderate, or high-intensity therapy based on guidelines. Insurance companies check this.

Lifestyle Modification Counseling: You must document that you discussed diet, exercise, and weight management. This affects quality metrics.

Lab Trend Analysis: Show comparison to previous values to demonstrate treatment response or lack thereof.

Medication Adherence: Document whether patient is taking medications as prescribed and address any barriers.

Side Effect Assessment: For patients on statins, document that you asked about muscle pain, weakness, and liver symptoms.

Treatment Goals: State specific LDL targets based on patient's risk category.

Common Mistakes to Avoid

Missing ASCVD Risk Score: This single number justifies your entire treatment plan. Don't skip it.

No Comparison to Previous Labs: Just listing current values doesn't show if treatment is working.

Vague Lifestyle Counseling: "Discussed diet and exercise" isn't enough. Document specifics about what you recommended.

Forgetting Secondary Cause Screening: Document that you considered thyroid disease, diabetes, or other causes of hyperlipidemia.

Not Documenting Statin Intolerance Properly: If changing statins, explain why with objective findings (CK level, symptom description).

No Treatment Goals: State the target LDL based on their risk category so there's a clear endpoint.

Final Thoughts

Writing SOAP notes for hyperlipidemia doesn't have to be complicated.

You need to show you assessed cardiovascular risk, justified your treatment decisions, counseled appropriately, and have a plan for monitoring.

That's it.

The key is having a system that captures these elements consistently without eating up your evening.

Whether you document manually or use soapnotes.doctor, make sure every note tells the story of why this patient needs continued management.

Your time is better spent preventing heart attacks than fighting with documentation.

That's why we built this tool.

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Ready to streamline your lipid management documentation?
Visit soapnotes.doctor and see how much time you can get back.