Cardiology SOAP Note

Date: [date of service]

Provider: [name and credentials]

Setting: [outpatient clinic / telehealth / post-hospital follow-up]

Visit Type: [new / established / urgent]

Chief Complaint: [primary reason in patient's terms] (Include relevant context such as post-discharge date or post-procedure follow-up.)

Subjective

[Interval history and HPI] (Begin with the chief complaint. Summarize symptom status since last encounter: chest pain/pressure characteristics; dyspnea at rest vs exertion, orthopnea, PND; palpitations; presyncope/syncope; lower-extremity edema; weight changes; exercise tolerance compared with baseline. Document functional status using NYHA class for heart failure or CCS class for angina when applicable. Note pertinent interval events including ED visits, hospitalizations, procedures, and medication changes by other providers. Include medication adherence and tolerance issues, home monitoring data if relevant, and patient goals or preferences when decisions are preference-sensitive. Document relevant history updates only when changed or directly relevant to today's visit.)

[Focused ROS – cardiovascular/pulmonary] (Include only if actually reviewed. If ROS is intentionally limited, state so explicitly. Omit entirely if not performed.)

Objective

Vitals: [BP, HR, RR, SpO2, weight with change from prior] (Include orthostatics if syncope or volume status is being evaluated.)

Exam: [pertinent cardiovascular and related findings] (Document only elements actually examined: general appearance; JVP and carotids; cardiac rhythm, rate, sounds, murmurs with grade/timing/radiation; lung auscultation; abdominal exam if volume status relevant; extremity edema with severity; peripheral pulses as indicated. If exam is limited, state the reason. Do not auto-populate normal findings for elements not assessed.)

Data Reviewed: [relevant studies with date, source, and key findings] (Include ECG, echocardiogram, stress testing, catheterization, device interrogation, and pertinent labs as applicable. Label studies as "independently interpreted" if applicable. State "No interval studies reviewed" or omit if none.)

Assessment & Plan

[One-sentence clinical summary] (Identify the patient, key cardiac conditions, and today's clinical question or decision point.)

[Problem 1]: [problem name/diagnosis]

Assessment: [stable / improving / worsening]; [severity or phenotype classification when relevant]; [key supporting data with dates]; [clinical trajectory since last visit].

Plan: [diagnostics ordered with rationale]; [medication changes with dose/frequency]; [monitoring plan]; [counseling/shared decision-making if material]; [coordination with other providers]; [follow-up interval and contingency triggers].

[Problem 2]: [problem name/diagnosis]

Assessment: [status, classification if relevant, key data with dates, trajectory].

Plan: [plan elements as above].

(Add additional problems in order of clinical priority: immediate risks first, then symptom drivers, then chronic conditions, then preventive/risk factors. Omit problems not relevant to today's encounter.)

Stable problems: [problem name] — stable; continue current regimen; [follow-up interval]. (Use for conditions without plan changes.)

Safety netting: [specific red flags and actions] (Include when initiating medication titration, changing anticoagulation, or pending high-risk results. Omit if not applicable.)

(If information needed for a decision is missing, document how it will be obtained and the interim plan.)