The Right Way to Write SOAP Notes for Cardiac Patients (Finally)

SOAP Notes for Cardiac Patients

Time is everything in cardiac care, and that includes documentation time.

A well-structured cardiac SOAP note should not take longer to write than it took to examine the patient.

Let's break down exactly how to document cardiac cases that are both clinically sound and refreshingly straightforward to complete.

Quick tip: I hacked SOAP notes and built a soapnotes.doctor so everybody would hack them as well. Head over to soapnotes.doctor, use the record button during a session, use the "save session" to get a tailored soap note to your need. HIPAA compliance. Military grade encryption. All you need.

A Jiffy into SOAP Notes

SOAP notes are that documentation format every medical student learns to love and hate in equal measure.

Four simple letters that structure how we think about patients: what they tell us (Subjective), what we find (Objective), what we think is going on (Assessment), and what we're going to do about it (Plan).

It's basically a way of stripping down medical documentation to its essential components.

Walk into any hospital, clinic, or medical facility worldwide, and you'll find the same four-section structure organizing patient information.

That's the beauty. The consistency.

It allows easy comprehension of patient documentation across people and time.

The SOAP note format has survived decades of healthcare evolution for one simple reason: it works.

The Right Way To Approach SOAP Notes for Cardiac Patients

Heart failure documentation can't be cookie-cutter. They shouldn't. They demand precision.

So I'll quickly chime in that the best way to approach them is to use a system that doesn't depend on your emotions on any faithful day.

This provides a better experience for your patients (you focus better on them), for you (you no longer stress about documentation) and for contingencies (since it's well documented).

To get started:

1. Sign up to soapnotes.doctor
2. Use the "start recording" button
3. Use the "save session" button when you're done
4. Voila!

Now for whatever reason you need to edit, you can easily do that using the tailorr button.

Want to use a different medical pattern? Perhaps your practice uses bullet points over paragraphs.

We built the tailorr feature for this.

Write them yourselves but better

Here's the problem with most cardiac SOAP notes: providers treat each section like they're filling out a form rather than telling a coherent note.

Subjective: Lead with the Cardiac Story, Not the Life Story

Your Subjective section for patients should immediately establish cardiac risk and acuity.

Don't start with "patient is a pleasant 67-year-old" when they're having chest pain.

You're not a therapist.

Lead with the main complaint: "Patient reports crushing substernal chest pain, 8/10 intensity, radiating to left arm, onset 2 hours ago."

Then build context: previous MI, current medications, compliance issues, functional status changes.

Save the social history for the end of this section, not the beginning.

Their job stress matters, but their troponin level matters more for immediate clinical decisions.

Structure your Subjective to answer:

• What's the cardiac problem?
• How long has it been going on?
• What makes it better or worse?
• How does this compare to their baseline cardiac function?

Don't forget the functional assessment questions that insurance companies and quality metrics actually care about: "Can patient climb one flight of stairs without stopping? Walk two blocks on level ground? Perform activities of daily living without dyspnea?"

Pro Tip:

Timing is also diagnostic. Document symptom onset precisely, not vaguely.

"Chest pain started at 3:47 PM during an argument with my spouse" tells a different cardiac story than "chest pain sometime this afternoon."

Include the patient's exact words for key symptoms.

"Feels like an elephant sitting on my chest" hits different than "mild chest discomfort."

These descriptions matter for risk stratification and often get lost when you paraphrase.

Objective: Organize by Priority

Stop listing vital signs like you're reading a grocery receipt.

Start with the most relevant findings first.

Lead with exam findings: heart sounds, murmurs, JVD, peripheral edema, pulse quality. Then move to respiratory findings that affect cardiac assessment: breath sounds, oxygen saturation, respiratory rate and effort.

Group your lab values logically: cardiac enzymes together, BNP levels prominently displayed, electrolytes that affect cardiac medications clearly noted.

Your EKG findings shouldn't be buried in paragraph three. If there are rhythm changes or ischemic findings, they belong at the top of your Objective section where they can't be missed.

Pro Tip:

For cardiac patients, what's NOT present is often as important as what is. "No S3 gallop, no JVD, no peripheral edema" tells the reader this patient isn't in heart failure.

"No chest wall tenderness, no reproducible pain with palpation" helps rule out musculoskeletal causes.

Don't assume the next provider will notice what you didn't document. Explicitly state negative cardiac findings that influence your assessment.

Assessment: Connect the Dots

This is where most cardiac SOAP notes fall apart.

Providers list differential diagnoses without explaining their reasoning or risk stratification.

Your Assessment should read like cardiac clinical thinking: "Chest pain consistent with unstable angina based on troponin elevation, EKG changes in leads II, III, aVF, and lack of response to sublingual nitroglycerin."

Address cardiac stability explicitly: "Patient hemodynamically stable with no signs of acute heart failure or cardiogenic shock."

Don't make the next provider guess whether this patient is crashing or stable.

Include cardiac risk factors in your reasoning: "Given history of diabetes, hypertension, and family history of CAD, maintaining high suspicion for ACS despite atypical presentation."

Pro Tip:

Specify the type of heart failure and functional class. "Heart failure with reduced ejection fraction, NYHA Class II" provides good information.

"Acute coronary syndrome, TIMI risk score 4" gives the next provider immediate risk context.

Reference established cardiac guidelines in your reasoning: "Per AHA/ACC guidelines, patient meets criteria for dual antiplatelet therapy initiation." This shows you're not making arbitrary decisions.

Assessment: Address the Trajectory

Your assessment shouldn't just diagnose the current problem—it should place this visit in the context of the patient's cardiac progression.

"Patient's heart failure appears to be progressing despite optimal medical therapy, with functional status declining from NYHA Class I to Class II over past three months."

This helps with prognosis and guides aggressive versus conservative management decisions.

Plan: Build Action Items

Every cardiac patient needs a safety net built into your plan. What happens if they get worse? What symptoms should trigger immediate return to ED? What's the escalation pathway if current interventions fail?

"Patient instructed to return immediately for chest pain lasting more than 5 minutes, shortness of breath at rest, or weight gain more than 3 lbs in 24 hours. Emergency contact numbers provided. Next appointment scheduled in 48 hours with earlier follow-up available if symptoms worsen."

Your Plan should prevent the 2 AM emergency calls by anticipating what could go wrong and providing clear instructions for patients and on-call providers.

Pro Tip:

Create decision trees for cardiac management. "If troponin remains elevated at 6-hour mark, proceed with cardiac catheterization. If troponin trending down and patient pain-free, consider stress testing tomorrow."

Include specific parameters for medication adjustments: "Increase lisinopril to 10mg daily if systolic BP remains above 140 and potassium below 4.5. Hold if systolic BP below 100 or potassium above 5.0."