Vascular Surgery SOAP Note

Date: [Date]

Patient: [Patient name or identifier]

Encounter Type: [new consult / follow-up / inpatient progress]

Author: [Author name and role]

Attending: [Attending name]

Subjective

Chief Complaint: [Chief complaint or consult question]

HPI: [1–2 sentence summary, then vascular-specific details: territory and laterality, time course and progression, functional impact, prior vascular interventions with dates, current antiplatelet/anticoagulant and statin therapy, smoking status] (For follow-ups, lead with interval changes. State "unknown" or "patient unsure" when information is unavailable rather than omitting.)

Relevant History: [Pertinent comorbidities affecting vascular decision-making, prior vascular procedures, current antiplatelet/anticoagulant/statin therapy, relevant allergies including contrast reactions or HIT history] (Include only history pertinent to today's vascular decision.)

ROS: [Targeted ROS relevant to vascular problem and perioperative risk] (Document only systems actually reviewed; avoid comprehensive ROS unless clinically indicated.)

Objective

Vitals: [Relevant vitals; include bilateral BP when indicated]

Exam: [General appearance, pertinent cardiopulmonary findings] (Document "not assessed" for components not examined; do not default to normal.)

• Vascular: [Pulses by territory with R/L comparison using consistent scale; Doppler signals with waveform quality when pulses not palpable; perfusion markers including capillary refill, temperature, color; edema location and severity]
• Wounds: [Location, size, base characteristics, drainage, surrounding skin] (Include only if wounds or tissue loss present.)

Diagnostics: [Noninvasive studies with key findings and interpretation; imaging with actionable findings; pending studies with follow-up responsibility] (Include date and source; specify whether report reviewed or images independently reviewed.)

Assessment

[1–2 line synthesis of patient, key vascular problems, and today's clinical decision]

1. [Vascular diagnosis with territory and laterality] — [severity classification if applicable: WIfI / Rutherford / CEAP / aneurysm diameter] — [stable / improving / worsening]
2. [Additional problems as applicable with classification and status]

Plan

(Organize by problem. Document only elements addressed today.)

[Problem: Diagnosis with territory/laterality]

• Goal: [Clinical goal of therapy]
• Diagnostics: [Planned tests with timing and responsible party]
• Medical therapy: [Antiplatelet/antithrombotic, statin, risk factor modification, smoking cessation, wound care/compression as relevant]
• Procedural plan: [Indication, urgency, approach with rationale, pre-procedure requirements, antithrombotic management] (Include only if procedure planned.)
• Counseling: [Risks/benefits/alternatives discussed, patient preferences and decision] (Include when intervention decisions discussed.)
• Follow-up: [Timing, surveillance schedule, return precautions]

(Repeat problem-based structure as needed. Omit elements not addressed; exception: explicitly note pending diagnostics with follow-up responsibility.)