SOAP Notes for Hypertension (with Examples)

Hypertension, commonly known as high blood pressure, is one of the most widespread health problems worldwide. What makes it especially dangerous is that it often shows no obvious symptoms, yet it slowly damages the heart, brain, kidneys, and blood vessels. Because of this silent nature, clear documentation becomes an essential part of managing the condition.

SOAP notes offer a structured and reliable way for healthcare professionals to record each patient’s symptoms, readings, lifestyle habits, and treatment decisions. They help not only in today’s visit, but also in long-term care, where small changes in blood pressure can significantly affect treatment choices. When written properly, SOAP notes make hypertension care more accurate, organized, and safe.

How to Write SOAP Notes for Hypertension

Hypertension is a long-term condition, so the goal of your SOAP note is not only to write what is happening today, but also to support long-term care. When writing SOAP notes for hypertension, focus on clear symptoms, accurate blood pressure readings, lifestyle habits, medicines, and risk factors. The information should help the healthcare team understand how the patient is doing now and how to manage their condition in the future.

Below is a detailed breakdown of what to include in each section.

1. Subjective (S)

The subjective section describes what the patient says in their own words. This part is very important in hypertension because many patients do not show clear symptoms. You should ask questions that help you understand how the patient feels and how they live. When documenting, include:

• Common symptoms such as headache, dizziness, blurred vision, chest pain, shortness of breath, or ringing in the ears (even if mild).
• Medication history, including whether the patient is taking their medicine on time, if they skip doses, or if they experience side effects from medication.
• Diet and lifestyle habits, especially how much salt they use in cooking, their intake of fried food, smoking status, alcohol use, caffeine use, stress level, and physical activity (exercise frequency).
• Family history of hypertension, heart disease, diabetes, or kidney disease, because these increase the risk of high blood pressure.

Write this section in the patient’s voice using their reported feelings and habits. Example: “Patient says they forget to take pills at night” or “Patient reports using high salt in daily meals.”

2. Objective (O)

The objective section includes measurable and observable information gathered during the examination. This shows the real and exact physical status of the patient. Key points to document:

• Blood pressure readings, and always write the exact numbers (e.g., 150/95 mmHg). Also note if measured in both arms or specific position (sitting, standing).
• Other vitals and measurements, such as heart rate, weight, BMI (to check if overweight or obese), temperature, and oxygen level if needed.
• Physical examination findings, such as edema (swelling in legs), abnormal heart sounds, vision problems, or shortness of breath.
• Laboratory results if available, including lipid profile (cholesterol levels), kidney function tests (creatinine, BUN), electrolyte levels, and blood glucose levels. These tests help identify complications and risk factors linked to hypertension.

The objective data should be precise and fact-based, without the patient’s personal opinions.

3. Assessment (A)

The assessment section is where the clinician interprets the findings. This is not just a diagnosis—it also reflects clinical reasoning. When writing this part, include:

• Hypertension stage, such as Stage 1, Stage 2, hypertensive urgency, or controlled hypertension. Labeling the stage helps guide treatment.
• Possible causes and risk factors, such as obesity, stress, poor diet, lack of exercise, family history, diabetes, smoking, alcohol use, or kidney disease.
• Complications, if present, like hypertensive retinopathy, heart enlargement, kidney damage, or headaches suggesting high pressure.
• Progress compared to the last visit, for follow-up patients. Describe whether the BP is improving, worsening, or staying the same.

Use clear medical reasoning: connect the symptoms, BP readings, lifestyle, and labs to the condition.

4. Plan (P)

The plan section describes what will happen next. This part must be actionable and easy to follow so that the patient understands how to manage their condition. Your plan should include:

• Medications, written with the drug name, dose, and frequency. Also note if the medicine is being continued, changed, or newly prescribed.
• Lifestyle instructions, such as reducing salt, eating more vegetables, increasing physical activity, weight reduction, quitting smoking, limiting alcohol, and managing stress.
• Follow-up schedule, based on the patient’s condition. For example, severe hypertension may require a 1–2 week follow-up, while controlled hypertension may need a check every 3 months.
• Diagnostic tests, if needed, such as ECG, kidney tests, lipid profile, urine albumin, or eye examination to check for complications.

The plan should be specific enough to guide treatment and simple enough for the patient to follow.

Hypertension SOAP Note Examples

SOAP Note #1 – Essential Hypertension (New Diagnosis)

S – Subjective

Patient (47-year-old male) reports frequent headaches and eye pressure for 2 months, worse in the morning. Denies chest pain, shortness of breath, dizziness, or syncope. Reports high stress job, sedentary lifestyle, and irregular diet (high salt, fast food 4–5x/week). No previous treatment for blood pressure. Denies tobacco or alcohol abuse. No family history except father with hypertension at age 52.

O – Objective

• BP: 158/96 mmHg (right arm, sitting, repeat 10 min: 160/98 mmHg)
• Pulse: 82 bpm
• BMI: 29.7 (overweight)
• General: Alert, no acute distress
• Cardiovascular: Regular rhythm, no murmurs
• Lungs: Clear bilaterally
• Labs (today): Pending (CMP, Lipid Panel, HbA1c, UA)

A – Assessment

• Primary essential hypertension (stage 2)
  Based on persistently elevated BP readings and lifestyle factors (high sodium diet, stress, sedentary habits). No red flags for secondary hypertension currently.

P – Plan

• Medication: Start Amlodipine 5 mg daily.
• Labs Ordered: CMP, Lipid Profile, HbA1c, Urinalysis.
• Lifestyle Advice:
  • Low-sodium DASH diet
  • Exercise: 30–45 min, 5x/week
  • Reduce fast food and caffeine
• Monitoring: Check BP at home daily; keep log.
• Follow-Up: Recheck BP and review labs in 4 weeks.

SOAP Note #2 – Chronic Hypertension With Poor Control

S – Subjective

62-year-old female with known hypertension for 8 years. Currently taking Losartan 50 mg daily, but admits to forgetting doses 3–4 times/week. Complains of fatigue and occasional mild morning headaches. Denies chest pain, palpitations, shortness of breath, edema, or vision changes. Reports high salt intake due to packaged foods. Family history positive for stroke (mother at 68).

O – Objective

• BP: 172/102 mmHg, repeat 166/104 mmHg
• Pulse: 76 bpm
• Weight: 84 kg, BMI 31 (obese)
• Eyes: No papilledema
• Heart: Regular rhythm, no gallop/murmur
• Extremities: No edema
• Prior labs (last month):
  • Elevated LDL (158 mg/dL)
  • HbA1c 5.6
  • Kidney function normal

A – Assessment

• Uncontrolled Hypertension, Stage 2
  Likely due to medication non-compliance and high sodium intake. Elevated cardiovascular risk due to obesity, dyslipidemia, and family history.

P – Plan

• Increase Losartan to 100 mg daily.
• Add Hydrochlorothiazide 12.5 mg daily for BP control.
• Compliance counseling: Use pill organizer + phone reminders.
• Dietary changes: Strict low-sodium (<2 g/day) + reduce packaged snacks.
• Recommend weight reduction (goal: −5% over 3 months).
• Start Atorvastatin 10 mg at night due to high LDL + risk factors.
• Follow-up in 2 weeks for BP check, then monthly.

SOAP Note #3 – Hypertension With Medication Side Effects

S – Subjective

54-year-old male taking Lisinopril 20 mg daily for 6 months reports persistent dry cough worsening over the last 3 weeks. Denies shortness of breath, wheezing, chest pain, or fever. Reports good medication compliance. Diet moderately healthy, exercises occasionally. No known drug allergies.

O – Objective

• BP: 138/88 mmHg
• Pulse: 80 bpm
• Weight: 82 kg
• Lungs: Clear, no wheezing
• Throat: Normal
• Heart: Normal S1/S2, no murmur
• Recent labs:
  • Electrolytes and kidney function normal
  • Lipid profile borderline elevated

A – Assessment

• Hypertension, controlled
• ACE-inhibitor–induced cough (likely due to Lisinopril)

P – Plan

• Discontinue Lisinopril
• Start Valsartan 80 mg daily
• Educate patient regarding expected improvement in cough within 1–4 weeks
• Continue lifestyle recommendations (moderate sodium, daily activity)
• Recheck BP and cough symptoms in 4 weeks
• Repeat lipid profile in 3 months; consider statin if persistent elevation

SOAP Note #4 – Hypertension + Overweight Adult

S – Subjective

38-year-old female presents for routine checkup. Reports occasional mild headaches after stress and excessive coffee intake. Denies dizziness, chest pain, palpitations, or blurred vision. No history of hypertension medication. Eats spicy and salty snacks daily. Drinks 3 cups of coffee/day. Family history: hypertension in mother and older sister.

O – Objective

• BP: 146/92 mmHg (repeat 148/90)
• HR: 88 bpm
• Weight: 78 kg
• Height: 1.58 m
• BMI: 31.2 (Obese)
• Heart: Normal S1/S2, no murmur
• Lungs: Clear
• No ankle edema or vision abnormalities
• Labs ordered today: Lipid panel, CMP, fasting glucose

A – Assessment

• Stage 1 Hypertension, likely related to obesity, high sodium intake, caffeine usage, and genetics.

P – Plan

• Start Lifestyle treatment first (no medication yet):
  • Reduce salt + avoid packaged/snack foods
  • Limit coffee to 1–2 cups/day
  • DASH diet
  • Exercise: brisk walk 45 mins x 5 days/week
• Check BP at home 3–5x/week
• Educate patient to record readings
• Medication only if BP remains high after 6–8 weeks
• Follow-up with BP logs in 6 weeks

SOAP Note #5 – Hypertension + Diabetes

S – Subjective

59-year-old male with Type 2 Diabetes (15 years) reports fatigue and occasional headaches. States he takes Metformin 1000 mg BID consistently. Currently on Hydrochlorothiazide 25 mg, but BP remains high. Denies chest pain, edema, dizziness, or shortness of breath. Reports high rice intake and limited exercise.

O – Objective

• BP: 156/94 mmHg
• Pulse: 84 bpm
• Weight: 85 kg
• BMI: 29.5
• Heart: Regular rhythm, no murmurs
• Eyes: No diabetic retinopathy (recent exam)
• Extremities: No edema, pulses normal
• Labs (last week):
  • HbA1c: 7.4%
  • eGFR: Normal
  • Lipids: Elevated LDL 142 mg/dL

A – Assessment

• Hypertension with Diabetes (Uncontrolled)
• High cardiovascular risk

P – Plan

• Add ACE inhibitor (Lisinopril 10 mg daily) — for kidney protection
• Continue Hydrochlorothiazide 25 mg
• Start Atorvastatin 20 mg daily due to high LDL + diabetes
• Diet: Lower carbohydrates + low sodium diet
• Encourage moderate exercise (30 min/day)
• Educate patient on kidney protection and BP goals ≤130/80
• Follow-up in 3 weeks for BP + medication response

Conclusion

Hypertension may be common, but its long-term risks make accurate documentation essential. Well-written SOAP notes allow healthcare professionals to follow a patient’s blood pressure trends, understand lifestyle influences, monitor medication response, and adjust treatment safely. With clear, structured writing, clinicians can prevent complications before they become serious and guide patients toward healthier daily habits.

Using the SOAP format is not just about organizing information, it is about improving patient outcomes. Each note becomes a record of meaningful decisions, clinical reasoning, and progress over time. By focusing on exact readings, lifestyle details, and objective data, any healthcare provider can deliver more consistent and effective care.

The more precise we are in documentation, the better we can manage hypertension and protect the patient’s future health. Small details in writing can lead to big differences in treatment.