Cardiac SOAP Notes (with Examples)

Cardiac problems are very common in clinics, hospitals, and emergency settings. Conditions like chest pain, palpitations, shortness of breath, and high blood pressure often require careful and structured documentation. A cardiac SOAP note helps the clinician write the patient story in a clear and organized way. SOAP stands for Subjective, Objective, Assessment, and Plan. This method keeps the note simple, professional, and easy for any other healthcare worker to understand. It also helps track symptoms, changes, and treatment progress over time.

When writing a SOAP note for a heart-related complaint, the clinician must focus on symptoms, physical findings, test results, risk factors, and any warning signs. Heart conditions can be serious if missed, so a good and detailed SOAP note is very important. It gives a clear snapshot of the patient’s current status and helps guide safe and effective care. The goal is to collect the most important information without writing unnecessary details that do not help the diagnosis.

In cardiac cases, the note also becomes helpful for legal protection, referrals, follow-up care, and long-term monitoring of the patient. Many heart patients come back several times, so good documentation builds a complete picture of their condition. Whether the patient complains of chest pressure, fast heartbeat, dizziness, or breathlessness, the SOAP format ensures nothing important is missed. Below, we explain the structure and then give common cardiac SOAP note examples you can use as models.

What to Include in a Cardiac SOAP Note

When writing a cardiac SOAP note, try to be clear, short, and specific. Heart conditions can look similar, so details matter. Here is what each part should include:

Subjective (S)

This is what the patient says. You write symptoms in the patient’s own words when possible. Include:

• Chest pain details (sharp, pressure, burning, heavy)
• Duration of symptoms
• Shortness of breath
• Palpitations or irregular heartbeat
• Dizziness, fainting, weakness
• Radiation of pain (arm, jaw, back)
• Risk factors (smoking, blood pressure, diabetes, cholesterol)
• Medication history
• Recent stress or exertion
• Family history of heart problems

Objective (O)

This is what you observe or measure. Include:

• Vital signs (BP, HR, RR, Temp, O₂ saturation)
• Heart sounds, murmurs, rhythm
• Lung sounds
• Edema or swelling
• ECG findings
• Lab results if available (troponin, cholesterol, BNP)
• Physical appearance: sweating, pale skin, anxious look

Assessment (A)

This is your clinical judgment. Write the possible diagnosis or what you think is happening, such as:

• Chest pain, rule out angina
• Hypertension
• Suspected arrhythmia
• Heart failure exacerbation
• Acute coronary syndrome (if severe symptoms)

Plan (P)

This is what you will do next. Include:

• Tests (ECG, blood tests, X-ray)
• Medications
• Lifestyle guidance
• Emergency instructions
• Follow-up schedule
• Referrals to cardiology

4 Cardiac SOAP Note Examples

Below are four cardiac SOAP note examples you can use for training, documentation practice, or learning.

Chest Pain

Subjective

Patient is a 48-year-old male who reports chest pain for the past 1 hour. Pain started while walking to work. He describes the pain as “heavy pressure” in the center of the chest. Pain radiates to the left arm and jaw. Pain level is 8/10. Patient feels short of breath and slightly nauseous. No vomiting. Pain does not improve with rest. No change with deep breathing or position. Denies cough or fever.

Patient reports similar mild chest discomfort 2–3 times in the past month, but it always lasted only a few minutes. Family history: father had a heart attack at age 55. Patient smokes 1 pack/day. No known history of heart disease. Has high blood pressure but does not take medication regularly. No recent trauma. No drug use.

Objective

Vital Signs:

• BP: 162/98 mmHg
• HR: 108 bpm, slightly irregular
• RR: 22 breaths/min
• O₂ saturation: 94% on room air
• Temp: 36.8°C

Physical Exam:

• Patient appears anxious, pale, and slightly sweaty.
• Heart: Tachycardic rhythm, no obvious murmurs, normal S1/S2.
• Lungs: Clear breath sounds bilaterally, no wheezing or crackles.
• Chest wall: No tenderness on palpation.
• Extremities: No swelling, no calf pain.
• Skin: Cool and damp.

Diagnostics:

• ECG in clinic shows ST-segment depression in leads V4–V6.
• Troponin: Pending.
• Blood glucose: Normal.

Assessment

Primary Assessment:

• Chest pain highly suspicious for unstable angina or evolving acute coronary syndrome (ACS).

Differential Diagnoses:

• Myocardial infarction (must rule out immediately)
• Angina pectoris
• Aortic dissection (less likely due to stable BP and no tearing pain)
• GERD (less likely due to radiation and exertion-triggered pain)
• Musculoskeletal chest pain (less likely due to no tenderness)

Given symptom duration, radiation, exertion trigger, risk factors (smoking, hypertension, family history), and ST changes on ECG, cardiac cause is strongly suspected.

Plan

• Send patient to Emergency Department immediately (urgent transfer).
• Administer aspirin 325 mg chewed, unless contraindicated.
• Begin oxygen 2 L/min if oxygen saturation decreases further.
• Place patient on continuous cardiac monitoring.
• Order:
  • Serial troponin (initial, 1 hour, 3 hours)
  • Full ECG evaluation
  • Chest X-ray
  • Basic metabolic panel, CBC, lipid panel
• Strict rest; avoid any exertion.
• Discuss risks and need for immediate evaluation by cardiology.
• Advise patient to avoid driving; arrange supervised transport.
• Document informed consent for emergency evaluation.

Palpitations

Subjective

Patient is a 34-year-old female who reports episodes of “fast and skipping heartbeat” for the past 5 days. Episodes come suddenly and last between 30 seconds to 3 minutes. Patient feels light-headed during episodes but has not fainted. No chest pain, but mild chest tightness is present sometimes. Symptoms are more noticeable at night and after drinking coffee.

Patient states she has been under a lot of stress at work. Drinks 3–4 cups of coffee daily and sometimes energy drinks. No recent illness or fever. Denies shortness of breath, swelling, or cough. No known heart disease. No medications. Family history negative for arrhythmias but positive for hypertension in mother.

Patient denies alcohol or drug use. No recent travel. No history of thyroid disease.

Objective

Vital Signs:

• BP: 126/82 mmHg
• HR: 112 bpm (irregular during episode)
• RR: 18 breaths/min
• O₂ saturation: 98%
• Temp: 36.7°C

Physical Exam:

• Patient alert, oriented, and mildly anxious.
• Heart: Irregular rhythm, tachycardic. No murmurs heard.
• Lungs: Clear, no crackles or wheezing.
• Neck: No jugular vein distention.
• Extremities: No edema, warm, good pulses.
• Thyroid gland: Normal size, no tenderness.

Diagnostics:

• ECG: Irregular rhythm with occasional premature beats; possible supraventricular tachycardia (SVT) during brief episode.
• Blood glucose: Normal.
• No labs yet; thyroid test and electrolytes ordered.

Assessment

Primary Assessment:

• Palpitations likely due to supraventricular tachycardia (SVT) or other benign arrhythmia.

Differential Diagnoses:

• Atrial fibrillation (needs monitoring to confirm)
• SVT
• Premature atrial or ventricular contractions (PAC/PVC)
• Anxiety-related tachycardia
• Caffeine-induced arrhythmia
• Hyperthyroidism (needs labs)

Risk factors include high caffeine intake and stress.

Plan

1. Reduce caffeine intake immediately (coffee + energy drinks).
2. Encourage hydration and adequate sleep.
3. Order diagnostic tests:
   • 12-lead ECG (complete reading)
   • Holter monitor (24–48 hours) to capture intermittent episodes
   • TSH + Free T4 (thyroid panel)
   • Basic metabolic panel (check potassium & magnesium)
4. Consider beta-blocker if heart rate remains consistently high or symptoms worsen.
5. Educate patient on vagal maneuvers (Valsalva, deep breathing) if SVT episode occurs.
6. Cardiology referral for arrhythmia evaluation.
7. Advise return to clinic immediately if:
   • Chest pain develops
   • Fainting occurs
   • Symptoms become more frequent or severe
8. Follow-up appointment in 1 week or sooner based on test results.

Hypertension With Symptoms

Subjective

Patient is a 52-year-old female who reports a constant headache and mild chest pressure for the last 24 hours. She also feels more tired than usual and noticed slight dizziness in the morning. Patient checked her blood pressure at home, and readings were between 168/100 mmHg and 175/105 mmHg today. She says the headache becomes stronger when her BP increases.

Patient has a history of hypertension for 6 years. She was prescribed medication but has missed doses for the past 2 weeks due to running out of refills. Denies vision loss, fainting, or severe chest pain. No shortness of breath. No swelling in legs. No recent illness. Diet includes high salt intake, especially processed foods. Sleeps only 5 hours per night due to work stress.

Family history: mother with high blood pressure and stroke. Patient denies alcohol or drug use. Drinks one cup of coffee daily.

Objective

Vital Signs:

• BP: 176/104 mmHg
• HR: 88 bpm
• RR: 16 breaths/min
• O₂ Saturation: 97%
• Temp: 36.6°C

Physical Exam:

• Patient alert but appears uncomfortable due to headache.
• Heart: Normal S1 and S2, regular rhythm, no murmurs.
• Lungs: Clear breath sounds in all fields.
• Neuro exam: No weakness, normal pupil response, no slurred speech.
• Extremities: No edema.
• Abdomen: Soft, non-tender.

Diagnostics:

• No ECG done yet (ordered).
• No blood tests available yet.
• Home BP log shows consistently elevated readings.

Assessment

Primary Assessment:

• Uncontrolled hypertension with symptoms (headache, chest pressure, dizziness).
• Likely due to medication non-compliance and high salt intake.

Differential Diagnoses:

• Hypertensive urgency
• Early hypertensive emergency (no severe symptoms yet)
• Anxiety-related BP increase
• Possible risk for stroke or cardiac strain

Given the patient’s long untreated period and high BP levels, immediate management is required.

Plan

1. Restart antihypertensive medication as previously prescribed.
2. Consider short-term adjustment to medication dose based on response.
3. Order the following tests:
   • ECG to check for LVH or ischemic changes
   • Basic metabolic panel (kidney function, electrolytes)
   • Urinalysis for protein
   • Lipid profile
4. Educate patient on:
   • Reducing salt intake
   • Drinking enough water
   • Avoiding processed foods
   • Stress reduction and improving sleep
5. Discuss medication adherence and possible refill reminders.
6. Advise patient to return immediately if she develops:
   • Severe chest pain
   • Sudden vision changes
   • Weakness or trouble speaking
   • Shortness of breath
7. Schedule follow-up in 3–5 days for BP check and test review.
8. Consider referral to a cardiologist if BP remains uncontrolled.

Heart Failure Exacerbation

Subjective

Patient is a 68-year-old male with a known history of congestive heart failure (CHF) who reports worsening shortness of breath for the past 4 days. He states he becomes breathless even while walking short distances and feels more tired than usual. Patient also reports needing two pillows to sleep due to difficulty breathing when lying flat. He noticed swelling in both legs and a weight gain of 2.5 kg over the past week.

Patient denies chest pain but reports mild chest tightness when walking. No fever, cough, or recent illness. Appetite decreased. Patient admits he ate salty food at multiple family gatherings last week. He has not been consistent with his diuretics because they “make him go to the bathroom too often.” No recent travel. No alcohol use.

Family history: heart disease in older brother. Lives alone and manages medications independently.

Objective

Vital Signs:

• BP: 150/90 mmHg
• HR: 96 bpm
• RR: 24 breaths/min
• O₂ saturation: 92% on room air
• Temp: 36.5°C

Physical Exam:

• Patient appears tired and slightly short of breath even at rest.
• Lungs: Bibasilar crackles present.
• Heart: Regular rhythm, no murmurs.
• Neck: Jugular venous distension visible at 45°.
• Extremities: Bilateral pitting edema (2+) in lower legs.
• Skin: Cool, slightly pale.
• Abdomen: Soft, non-tender but mildly distended.

Diagnostics:

• ECG: Normal sinus rhythm.
• Weight increased compared to last visit.
• BNP and chest X-ray ordered but pending.

Assessment

Primary Assessment:

• Heart failure exacerbation likely caused by fluid overload, high salt intake, and poor medication adherence.

Differential Diagnoses:

• Pulmonary edema
• Pneumonia (less likely due to lack of fever or cough)
• COPD exacerbation (no wheezing or history)
• Angina without pain (still needs monitoring)

Clinical signs strongly support fluid retention and worsening CHF.

Plan

1. Increase diuretic dosage (per previous CHF plan).
2. Limit salt and fluid intake strictly.
3. Order the following:
   • BNP
   • Chest X-ray
   • ECG full reading
   • Basic metabolic panel (check kidney function + electrolytes)
4. Educate patient on:
   • Daily weight tracking
   • Calling clinic if weight increases by >2 kg in 2 days
   • Taking diuretics regularly
   • Avoiding salty foods
5. Encourage sleeping with extra pillows until symptoms improve.
6. Consider supplemental oxygen if O₂ saturation drops further.
7. Schedule follow-up in 2–3 days or sooner if symptoms worsen.
8. Discuss possible home health support if medication adherence continues to be difficult.
9. Refer to cardiology for ongoing heart failure management review.

The Bottom Line

A cardiac SOAP note is a very important tool for documenting heart-related symptoms in a simple and organized way. When written correctly, it helps clinicians understand the patient’s problem, choose the right tests, and provide safe treatment. Good documentation also supports better communication between healthcare teams, especially in serious conditions like chest pain or arrhythmias. Using the SOAP format keeps every note clear, structured, and focused on what truly matters. The examples above can guide students and new clinicians in writing stronger, professional cardiac notes with confidence.