SOAP Note Template (Cardiology)
Published: 10/22/2025
About this template:
This cardiology SOAP note template enables thorough documentation of cardiac evaluations and interventions. It includes sections for cardiovascular examination findings, diagnostic test results, risk stratification, and evidence-based treatment protocols. The template supports comprehensive documentation of conditions from arrhythmias to heart failure, making it ideal for both clinic visits and hospital consultations.
Preview template
Subjective: 62-year-old male with history of hypertension and hyperlipidemia presents for cardiac follow-up. Reports occasional substernal chest pressure with exertion (climbing two flights of stairs), relieved with rest after 2-3 minutes. Denies shortness of breath at rest, orthopnea, or paroxysmal nocturnal dyspnea. No palpitations or syncope. Currently taking lisinopril 20mg daily, atorvastatin 40mg daily, and aspirin 81mg daily. Adherent to medications.
Objective: BP 142/88 mmHg, pulse 72 regular. Cardiovascular examination reveals normal S1 and S2 without murmurs, rubs, or gallops. Jugular venous pressure not elevated. No peripheral edema. Lungs clear bilaterally. ECG shows normal sinus rhythm with no acute ST-T wave changes. Lipid panel: Total cholesterol 185, LDL 98, HDL 48, triglycerides 195.
Assessment and Plan:
- Stable angina pectoris, concerning for coronary artery disease
- Hypertension, suboptimally controlled
- Hyperlipidemia on statin therapy
- Order exercise stress test to assess for inducible ischemia
- Increase lisinopril to 40mg daily for better blood pressure control
- Continue current atorvastatin dose, LDL at goal
- Add nitroglycerin sublingual PRN for chest pain episodes
Patient Education:
- Reviewed warning signs of acute myocardial infarction and when to call 911
- Discussed importance of medication adherence and lifestyle modifications
- Advised on cardiac-healthy diet (Mediterranean style) and regular aerobic exercise as tolerated
- Instructed on proper use of sublingual nitroglycerin if prescribed
Follow-up in 2 weeks to review stress test results and assess blood pressure response to medication adjustment.
