The 2026 Guide to Stroke SOAP Note Examples for Healthcare Providers

If you've ever struggled to document stroke patients in a way that captures clinical urgency while meeting documentation requirements, this guide is for you.

I've talked to countless emergency physicians, neurologists, and hospitalists who face the pressure of documenting stroke cases thoroughly while managing time-sensitive interventions.

The reality is that stroke documentation has specific requirements that go beyond typical medical notes.

Insurance companies and quality reviewers want to see clear documentation of symptom onset time, NIHSS scores, contraindications screening, door-to-needle times, and evidence-based care pathways.

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

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

🧾 What SOAP Notes Really Are (And Why They Matter for Stroke Care)

SOAP notes might feel like bureaucratic busywork, but they serve a critical purpose in stroke care.

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 stroke specifically, SOAP notes are critical because they demonstrate:

• Precise documentation of symptom onset time and last known well time
• Systematic neurological assessment with standardized scoring (NIHSS)
• Appropriate screening for thrombolytic therapy eligibility
• Time-sensitive decision-making and interventions
• Adherence to stroke protocols and quality metrics
• Medical necessity for acute interventions, imaging, and rehabilitation

SOAP stands for:

• S — Subjective: What the patient or witnesses report about symptom onset, timeline, events leading up to stroke, and current symptoms.
• O — Objective: Your clinical findings including vital signs, neurological exam, NIHSS score, imaging results, and laboratory values.
• A — Assessment: Your clinical diagnosis with stroke type, territory, severity assessment, and etiology determination.
• P — Plan: Your treatment plan including thrombolytic therapy decisions, acute interventions, stroke unit admission, secondary prevention, and rehabilitation planning.

This structure keeps your documentation organized, defensible, and compliant with stroke quality metrics.

You're not just recording what happened—you're building a clinical narrative that justifies time-sensitive interventions and demonstrates adherence to evidence-based protocols.

How You Can Approach Stroke SOAP Notes

There's no single correct method for writing stroke SOAP notes, but some approaches work better than others depending on your 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 thoroughly despite the urgency. The challenge is it's time-consuming, and in acute stroke care, every minute matters for both patient outcomes and documentation requirements.

2. SOAP Notes Doctor

You record your examination findings or dictate your observations during or after the acute phase, and the tool automatically structures everything into proper SOAP format. It maintains consistency, saves crucial time, and ensures you never miss critical components that quality reviewers and insurance companies look for in stroke documentation.

How to Make Stroke SOAP Notes Faster

One of the biggest complaints I hear from providers managing stroke patients is the tension between urgent care and thorough documentation.

You've just completed a rapid assessment, initiated thrombolytic therapy, and coordinated multiple consultations, and now you need to document everything meticulously for quality metrics and potential litigation.

The pressure is real: documentation must capture exact timing, detailed neurological findings, and decision-making rationale, all while you're managing an unstable patient.

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
✅ Meet quality metrics without sacrificing patient care time

With soapnotes.doctor, you can record during or right after the acute phase, add rough notes about specific findings, or even upload audio later. The system converts everything into compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness that quality reviewers require, but without manually typing every detail during critical moments.

Maybe you noted specific findings?

"Last known well 0730, right hemiparesis, facial droop, aphasia, NIHSS 14, CT negative, tPA given 0952, door-to-needle 38 minutes."

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

Example 1: Acute Ischemic Stroke, tPA Administration

Patient: 67-year-old male
Chief Complaint: Sudden onset right-sided weakness and speech difficulty
Arrival Time: 09:14
Visit: Emergency department stroke code

S – Subjective:

Per wife, patient was normal at breakfast (07:30). At approximately 08:45, while reading newspaper, suddenly developed right arm weakness and difficulty speaking. Wife called 911 immediately. EMS arrival 08:58, hospital arrival 09:14. Last known well time: 07:30 (134 minutes ago). Patient reports understanding questions but cannot speak clearly. Denies headache, chest pain, recent trauma, or recent surgery. No recent bleeding. Wife confirms patient takes aspirin 81mg daily and atorvastatin. No history of previous stroke. History significant for hypertension and hyperlipidemia.

O – Objective:

Arrival Vitals: BP 168/94, HR 82 regular, RR 16, O2 sat 98% RA, Temp 98.4°F, Glucose 118 mg/dL
General: Alert, following commands, appears frustrated
NIHSS Score: 14 (1a-0, 1b-1, 1c-0, 2-2, 3-0, 4-0, 5-4, 6-4, 7-0, 8-2, 9-0, 10-0, 11-1)
Neurological: Right facial droop, expressive aphasia, right arm drift with no movement against gravity, right leg drift, decreased sensation right side, no neglect
Cardiovascular: Regular rhythm, no murmurs
Pulmonary: Clear bilaterally
CT Head (09:28): No hemorrhage, no early ischemic changes, no mass effect
CTA (09:35): Left MCA M1 segment occlusion
Labs: INR 1.0, platelets 245K, creatinine 0.9

A – Assessment:

Acute ischemic stroke, left MCA distribution with large vessel occlusion (M1 segment). NIHSS 14 indicating moderate to severe deficit. Patient within thrombolytic window (last known well 134 minutes). No contraindications to tPA identified. Patient meets criteria for both IV tPA and mechanical thrombectomy consideration.

P – Plan:

Acute Intervention: IV alteplase (tPA) 0.9 mg/kg (total 72 mg) administered at 09:52 (door-to-needle time 38 minutes, last known well to treatment 142 minutes). 10% bolus given over 1 minute, remainder over 60 minutes. Neurology consulted, recommended transfer to comprehensive stroke center for potential thrombectomy given LVO. Interventional neuroradiology accepting transfer.

Monitoring: Neuro checks every 15 minutes during tPA infusion and for 2 hours post-infusion, then hourly for 24 hours. Blood pressure goal less than 185/110 during and after tPA. NPO for aspiration precautions pending swallow evaluation.

Transfer: Air ambulance arranged to University Medical Center for thrombectomy evaluation. Stroke team activated at receiving facility. All imaging transmitted electronically.

Medications: TPA as above, continue home statin, hold aspirin for 24 hours post-tPA. Nicardipine drip available for BP management if needed.

Documentation: Stroke code activated 09:16, tPA decision time 09:45. Family updated on treatment, risks, benefits, and transfer plan. Patient/family verbalized understanding. Core measures documented for quality metrics.

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Example 2: Post-Stroke Follow-Up, Rehabilitation Phase

Patient: 71-year-old female
Event: Ischemic stroke 3 weeks ago (right MCA territory)
Chief Complaint: Follow-up stroke clinic visit
Visit: Outpatient neurology follow-up

S – Subjective:

Patient presents for follow-up 3 weeks post-ischemic stroke. Reports continued left-sided weakness but notes gradual improvement. Currently in acute inpatient rehabilitation facility. Able to stand with assistance, taking steps with walker. Left hand function limited, can grasp but no fine motor control. Speech has improved significantly, no longer aphasic but reports occasional word-finding difficulty. Denies recurrent symptoms, headache, vision changes, or new weakness. Mood is positive, motivated for therapy. Participating in PT, OT, and speech therapy daily. No swallowing difficulties, tolerating regular diet. Medications taken as prescribed by rehabilitation team.

O – Objective:

Vitals: BP 132/78, HR 74 regular, O2 sat 97% RA
General: Alert, oriented x3, conversing appropriately
Neurological: Left facial droop (mild, improved), speech fluent with mild word-finding pauses, left arm strength 3/5 proximally, 2/5 distally, left leg 4/5, sensory intact, gait not assessed (using wheelchair)
NIHSS: 4 (improved from admission score of 12)
Labs: LDL 78 mg/dL (on high-intensity statin), HbA1c 6.1%, TSH normal
MRI Brain (1 week post-stroke): Right MCA infarct, no hemorrhagic transformation
Echocardiogram: Normal EF, no thrombus, trace mitral regurgitation, no PFO
Carotid Ultrasound: Bilateral less than 30% stenosis

A – Assessment:

71-year-old female status post right MCA ischemic stroke 3 weeks ago with residual left hemiparesis, significantly improved from admission. NIHSS improved from 12 to 4. Stroke etiology likely cardioembolic vs. small vessel disease given imaging and workup. Good rehabilitation progress. Risk factors include hypertension and hyperlipidemia, now optimized on medications. No evidence of atrial fibrillation on telemetry monitoring during hospitalization.

P – Plan:

Secondary Prevention: Continue aspirin 81mg daily, atorvastatin 80mg daily, lisinopril 10mg daily for blood pressure control. No anticoagulation indicated given negative cardiac workup and no atrial fibrillation. Target BP less than 130/80, LDL less than 70. Encouraged lifestyle modifications including low-sodium diet, regular exercise as tolerated, smoking cessation resources provided (patient denies current smoking).

Rehabilitation: Continue current inpatient rehabilitation program with plan for discharge to home with outpatient therapy in approximately 2 weeks. Rehabilitation goals include independent ambulation with assistive device and improved left upper extremity function for ADLs.

Monitoring: Scheduled for 72-hour Holter monitor as outpatient to screen for paroxysmal atrial fibrillation. Follow-up MRI brain in 3 months to assess evolution. Return to stroke clinic in 3 months or sooner if recurrent symptoms.

Education: Reviewed stroke warning signs (FAST - Face, Arms, Speech, Time). Patient and family instructed to call 911 immediately for any sudden neurological symptoms. Discussed seizure precautions (no driving until cleared by neurology). Patient verbalized understanding of medication regimen and warning signs.

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Example 3: TIA (Transient Ischemic Attack) Evaluation

Patient: 58-year-old male
Chief Complaint: Episode of temporary speech difficulty and right arm numbness
Visit: Emergency department evaluation

S – Subjective:

Patient presented to ED reporting transient neurological symptoms. This morning at approximately 11:00 AM, while at work, suddenly developed difficulty speaking and right arm numbness/tingling. Symptoms lasted approximately 15-20 minutes then completely resolved. Co-worker noticed slurred speech and called 911. By EMS arrival at 11:25, symptoms had resolved. Patient now reports feeling completely normal. Denies headache, vision changes, weakness, facial droop, or confusion. No trauma. Medical history significant for hypertension (not well-controlled), type 2 diabetes, and 30 pack-year smoking history. Takes lisinopril irregularly, metformin daily. No previous stroke or TIA.

O – Objective:

Vitals: BP 162/96, HR 88 regular, RR 14, O2 sat 98% RA, Glucose 156 mg/dL
General: Alert, no acute distress
Neurological: Complete neurological exam normal. NIHSS 0. Cranial nerves II-XII intact, strength 5/5 all extremities, sensation intact, coordination normal, gait normal, speech fluent without dysarthria or aphasia.
Cardiovascular: Regular rhythm, no murmurs or carotid bruits
CT Head: No acute hemorrhage or infarct
CTA Head/Neck: 70% left internal carotid artery stenosis, right ICA 40% stenosis
Labs: Troponin negative, BNP 45, glucose 156, HbA1c 8.2%, lipid panel pending
ECG: Normal sinus rhythm, no atrial fibrillation
Telemetry: Continuous monitoring, no arrhythmias detected

A – Assessment:

Transient ischemic attack (TIA), resolved. High-risk features include significant carotid stenosis (70% left ICA), multiple vascular risk factors (poorly controlled hypertension, diabetes, smoking), and symptom duration greater than 10 minutes. ABCD² score 5 (moderate-high risk for subsequent stroke). Likely mechanism is large vessel atherosclerotic disease given carotid stenosis ipsilateral to symptoms.

P – Plan:

Admission: Admit to stroke unit for expedited workup and risk stratification given high ABCD² score and significant carotid stenosis.

Antiplatelet Therapy: Initiated dual antiplatelet therapy with aspirin 325mg loading dose followed by 81mg daily plus clopidogrel 75mg daily for 21 days per TIA guidelines, then transition to single agent.

Imaging: MRI brain with DWI ordered to assess for acute infarction (often positive despite symptom resolution). Echocardiogram ordered to evaluate for cardiac source.

Vascular Surgery Consultation: Consulted for evaluation of symptomatic high-grade carotid stenosis. Patient likely candidate for carotid endarterectomy given greater than 70% stenosis with recent symptoms.

Risk Factor Management: Increased lisinopril dose for better BP control, target less than 130/80. Diabetes management optimization, endocrinology referral for outpatient follow-up. Initiated high-intensity statin therapy (atorvastatin 80mg). Smoking cessation counseling provided, nicotine replacement offered.

Monitoring: Continuous telemetry for 24-48 hours to screen for atrial fibrillation. Neuro checks every 4 hours. NPO after midnight for possible carotid procedure.

Education: Extensive counseling on stroke warning signs and need for immediate 911 activation. Emphasized critical importance of medication compliance and risk factor modification. Patient verbalized understanding and motivation for lifestyle changes given "wake-up call." Family meeting scheduled to discuss carotid intervention options.

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Key Components Insurance Companies Look For in Stroke SOAP Notes

When reviewing your stroke documentation, insurance companies and quality reviewers specifically want to see:

1. Precise Timing Documentation

Last known well time, symptom onset, arrival time, door-to-CT time, door-to-needle time. These metrics determine quality measure compliance.

2. NIHSS Score

Standardized stroke severity assessment. Required for quality reporting and justifies treatment intensity and rehabilitation needs.

3. Thrombolytic Eligibility Screening

Documentation of inclusion/exclusion criteria, contraindications considered, and shared decision-making for tPA administration.

4. Imaging Results

Clear documentation of CT/MRI findings, vessel imaging, and how results influenced treatment decisions.

5. Secondary Prevention Plan

Antiplatelet/anticoagulation therapy, statin therapy, blood pressure management, and risk factor modification addressing stroke etiology.

6. Rehabilitation Assessment

Functional deficits, therapy needs, and discharge planning demonstrating appropriate level of care and services.

Common Mistakes to Avoid

Vague Timing: "This morning" instead of exact time. Precise timing is critical for thrombolytic windows and quality metrics.

Missing NIHSS: Not documenting NIHSS score or only providing total without component scores. Both initial and follow-up scores are important.

Incomplete Contraindication Review: Failing to document that you screened for tPA contraindications, even when patient isn't a candidate.

No Last Known Well: Documenting symptom onset without establishing last known well time, which determines treatment window.

Forgetting Door Times: Not recording door-to-CT and door-to-needle times, which are core quality measures.

Vague Etiology: Not documenting stroke mechanism (large vessel, cardioembolic, small vessel, cryptogenic) which drives secondary prevention.

Missing Deficits: Incomplete neurological exam documentation. Every component matters for disability assessment and rehabilitation planning.

Final Thoughts

Stroke SOAP notes don't need to be overwhelming.

They need to be thorough, yes, but they don't need to compromise patient care time.

The key is having a system that captures the right information without making you choose between documentation and time-sensitive interventions.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that demonstrates quality care and satisfies regulatory requirements.

Your time is better spent delivering rapid interventions and coordinating care 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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