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 soapnotes.doctor so everybody could 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 story.

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

Your Subjective section for cardiac 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 writing a character reference.

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 actionable 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."

Complete Cardiac SOAP Note Examples

Now let's look at three complete examples that show different cardiac scenarios you'll encounter.

Example 1: Acute Chest Pain - Rule Out MI

Patient: 62-year-old male
Visit Type: Emergency department
Chief Complaint: Chest pain for 2 hours

S – Subjective:

Patient presents with sudden onset substernal chest pain that began 2 hours ago while mowing lawn. Describes pain as "heavy pressure," 8/10 intensity, radiating to left arm and jaw. Associated with diaphoresis, nausea, and mild shortness of breath. Pain not relieved by rest. Denies prior episodes of similar pain. Medical history significant for hypertension (on lisinopril 20mg daily) and hyperlipidemia (on atorvastatin 40mg daily). Former smoker, quit 5 years ago, 30 pack-year history. Father had MI at age 58. Denies recent cocaine use. Takes medications as prescribed. Functional status at baseline: able to walk 2 miles daily without symptoms until today.

O – Objective:

Vitals: BP 158/94, HR 102 (regular), RR 20, O2 sat 96% on room air, Temp 98.4°F
General: Anxious-appearing male, diaphoretic, in moderate distress
Cardiovascular: Tachycardic but regular rhythm, S1 S2 normal, no S3 or S4 gallop, no murmurs, JVD not elevated, peripheral pulses 2+ and symmetric, no peripheral edema
Pulmonary: Clear to auscultation bilaterally, no crackles or wheezes, unlabored respirations
Chest wall: No tenderness to palpation, pain not reproducible
EKG: Sinus tachycardia at 104 bpm, 1mm ST elevation in leads II, III, aVF, no prior EKG available for comparison
Labs: Troponin I 0.8 ng/mL (elevated, normal less than 0.04), BNP 145 pg/mL (normal), Creatinine 1.1 mg/dL, Potassium 4.2 mEq/L, Hemoglobin 14.2 g/dL

A – Assessment:

62-year-old male presenting with acute inferior STEMI based on clinical presentation of prolonged substernal chest pain with radiation, associated symptoms, ST elevation in inferior leads, and elevated troponin. TIMI risk score 4 (age greater than 65, known CAD risk factors, ST changes, positive cardiac biomarkers). Patient is hemodynamically stable at this time without signs of cardiogenic shock or acute heart failure. High-risk features include first presentation of chest pain, significant troponin elevation, and ST elevation on EKG. Immediate reperfusion therapy indicated per AHA/ACC STEMI guidelines.

P – Plan:

STEMI protocol activated. Cardiology consulted, cardiac catheterization lab notified for emergent intervention. Aspirin 325mg chewed immediately. Loading dose clopidogrel 600mg administered. Heparin bolus 60 units/kg (4,200 units) given, followed by infusion at 12 units/kg/hr. Sublingual nitroglycerin 0.4mg given x3 with minimal pain relief. Started morphine 2mg IV for ongoing pain. Initiated metoprolol 5mg IV for tachycardia and cardiac protection. Patient transferred to cath lab for percutaneous coronary intervention. Family notified and present at bedside. Strict return precautions discussed but patient proceeding directly to cath lab. Will reassess post-procedure for need for ICU admission versus telemetry monitoring. Serial troponins and EKGs ordered post-intervention to assess for resolution.

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Example 2: Heart Failure Exacerbation Follow-Up

Patient: 71-year-old female
Visit Type: Cardiology follow-up
Chief Complaint: Worsening shortness of breath and leg swelling

S – Subjective:

Patient with known heart failure (EF 30%, HFrEF) presents for urgent follow-up due to worsening symptoms over past week. Reports increasing dyspnea on exertion, now short of breath walking from bedroom to bathroom (previously able to walk one block). Orthopnea developed 4 days ago, now sleeping in recliner with 3 pillows. Two episodes of paroxysmal nocturnal dyspnea this week. Notes bilateral lower extremity edema, "socks leaving deep marks." Weight increased from baseline 148 lbs to 156 lbs over past 5 days (8 lb gain). Denies chest pain, palpitations, or syncope. Admits to dietary indiscretion at family gathering 6 days ago (ham dinner, likely high sodium). Taking furosemide 40mg daily but ran out 2 days ago and hasn't refilled. Takes carvedilol 12.5mg BID and lisinopril 10mg daily consistently. No recent medication changes. Last hospitalization for heart failure 6 months ago.

O – Objective:

Vitals: BP 142/88, HR 92 (regular), RR 22, O2 sat 89% on room air (improves to 94% on 2L NC), Weight 156.4 lbs (up 8.4 lbs from last visit 3 weeks ago)
General: Mild respiratory distress, speaking in short sentences, appears fatigued
Cardiovascular: Tachycardic, regular rhythm, S3 gallop present, JVD elevated to 10cm, PMI displaced laterally, 2+ pitting edema bilateral lower extremities to knees
Pulmonary: Bibasilar crackles extending halfway up lung fields, decreased breath sounds at bases, dullness to percussion at bases bilaterally
Abdomen: Soft, non-tender, no hepatomegaly, no ascites
Labs: BNP 1,240 pg/mL (baseline 300-400), Creatinine 1.6 mg/dL (baseline 1.2), Potassium 4.1 mEq/L, Sodium 136 mEq/L
Chest X-ray: Cardiomegaly, pulmonary vascular congestion, bilateral pleural effusions

A – Assessment:

71-year-old female with chronic systolic heart failure (HFrEF, EF 30%) presenting with acute decompensation secondary to medication non-adherence (ran out of diuretic) and dietary indiscretion. Currently NYHA Class IV symptoms with clinical and radiographic evidence of volume overload. Elevated BNP significantly above baseline confirms acute decompensation. Mild worsening renal function (creatinine 1.6 from baseline 1.2) likely prerenal due to poor forward flow. Hypoxia present but responsive to supplemental oxygen. Patient demonstrates signs of right and left heart failure (JVD, peripheral edema, pulmonary congestion). Requires aggressive diuresis but hemodynamically stable for outpatient management at this time given improvement with oxygen and patient preference to avoid hospitalization if possible.

P – Plan:

Administered furosemide 80mg IV in clinic with close monitoring. Patient produced 600mL urine within 90 minutes with subjective improvement in dyspnea. Increased home furosemide to 80mg PO twice daily (from 40mg daily). Added metolazone 5mg PO daily to take 30 minutes before morning furosemide dose for synergistic diuresis. Continue carvedilol 12.5mg BID and lisinopril 10mg daily (holding uptitration given acute decompensation). Initiated supplemental oxygen 2L continuous via nasal cannula at home until symptoms improve. Strict fluid restriction to 1.5L daily and sodium restriction to less than 2g daily. Patient to weigh twice daily and call if weight increases or doesn't decrease by 2-3 lbs over next 2 days. Arranged visiting nurse for daily weights and medication compliance monitoring. Recheck BMP in 2 days to monitor renal function and electrolytes with aggressive diuresis. Urgent follow-up in 3 days for reassessment. Set up automatic pharmacy refill program to prevent future medication lapses. Strict return precautions: go to ED immediately if worsening shortness of breath, chest pain, confusion, or unable to tolerate oral medications. If no significant improvement within 48-72 hours or if symptoms worsen, plan for hospital admission for IV diuresis. Patient and family verbalized understanding of seriousness of situation and agreed to close monitoring plan.

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Example 3: New Atrial Fibrillation with RVR

Patient: 68-year-old male
Visit Type: Urgent care visit
Chief Complaint: Heart racing and lightheadedness

S – Subjective:

Patient presents with sudden onset palpitations that began 3 hours ago while watching television. Describes sensation of "heart fluttering and racing." Associated with lightheadedness when standing but no syncope. Mild shortness of breath, denies chest pain. No prior history of arrhythmias or palpitations. Medical history includes hypertension and type 2 diabetes, both well-controlled on medications. Takes metoprolol 50mg daily for hypertension, metformin 1000mg twice daily for diabetes. No history of stroke or TIA. Denies recent illness, caffeine excess, or alcohol use (reports 1-2 beers weekly). No family history of sudden cardiac death or arrhythmias. Functional status at baseline: walks 1 mile daily without symptoms.

O – Objective:

Vitals: BP 138/92, HR 142 (irregularly irregular), RR 18, O2 sat 96% on room air, Temp 98.6°F
General: Alert, anxious-appearing, no acute distress at rest
Cardiovascular: Tachycardic with irregularly irregular rhythm, variable intensity S1, no murmurs or gallops, JVD not elevated, no peripheral edema, peripheral pulses 2+ but irregular
Pulmonary: Clear to auscultation bilaterally, no respiratory distress
Neurologic: Alert and oriented x3, no focal deficits, cranial nerves intact, strength 5/5 all extremities
EKG: Atrial fibrillation with rapid ventricular response at 142 bpm, no ST segment changes, no Q waves
Labs: Troponin I less than 0.04 ng/mL (normal), TSH 2.1 mIU/L (normal), Electrolytes within normal limits

A – Assessment:

68-year-old male with new-onset atrial fibrillation with rapid ventricular response (rate 142 bpm). First documented episode of atrial fibrillation, unclear duration but likely less than 12 hours based on symptom onset. Patient hemodynamically stable without signs of heart failure or acute coronary syndrome. CHA2DS2-VASc score 3 (age, hypertension, diabetes) indicating moderate-high stroke risk and need for anticoagulation consideration. HAS-BLED score 1 (hypertension, low bleeding risk). Currently on metoprolol 50mg daily which is insufficient for rate control in atrial fibrillation. Etiology likely primary cardiac (age-related atrial remodeling) given normal thyroid function and absence of secondary causes. Requires rate control and initiation of anticoagulation per guidelines.

P – Plan:

Administered metoprolol 5mg IV slowly for acute rate control. Heart rate decreased to 108 bpm after 20 minutes with improvement in symptoms. Increased home metoprolol to 100mg twice daily for chronic rate control. Patient to monitor heart rate twice daily and keep log. Initiated apixaban 5mg twice daily for stroke prevention (chose DOAC over warfarin given patient preference and lack of contraindications). Provided extensive education on importance of anticoagulation compliance and bleeding precautions. Ordered transthoracic echocardiogram to assess cardiac structure, function, and rule out valvular disease or left atrial thrombus. Scheduled cardioversion consultation if patient remains in atrial fibrillation at follow-up, though given uncertain duration, will need 3-4 weeks of anticoagulation before cardioversion attempt per guidelines. Referred to cardiology for ongoing atrial fibrillation management and consideration of catheter ablation if rhythm control strategy pursued. Patient education on atrial fibrillation, stroke risk, and medication importance provided with written materials. Strict return precautions: return immediately for chest pain, severe shortness of breath, syncope, uncontrolled bleeding, or neurologic symptoms concerning for stroke. Follow-up in 1 week to assess rate control and medication tolerance. Patient verbalized understanding of diagnosis, stroke risk, and treatment plan.

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Key Documentation Points for Cardiac SOAP Notes

Risk Stratification: Always include validated risk scores when applicable (TIMI, GRACE, CHA2DS2-VASc, HAS-BLED, NYHA class). These provide objective risk assessment.

Medication Details: Document specific cardiac medications, doses, and adherence. Note when medications were started, why they were chosen, and barriers to uptitration.

Functional Status: Include baseline functional capacity and current limitations. This drives treatment decisions and demonstrates progression or improvement.

Hemodynamic Stability: Explicitly state whether patient is stable, compensated, or decompensating. Don't make the next provider guess.

Timeline and Trajectory: Show how this visit compares to previous visits and baseline status. Is the patient improving, stable, or declining?

Clear Safety Parameters: Document specific symptoms requiring immediate return to care and escalation pathways if interventions fail.

Guideline References: When appropriate, reference AHA/ACC guidelines to show evidence-based decision-making.

Remember: cardiac documentation isn't just about covering yourself legally - it's about creating a clear roadmap that any provider can follow to deliver safe, effective care to your patient.