What is an example of a SOAP note for a patient with hypertension?

Example SOAP Note for Hypertension Patient

Subjective (S)

A comprehensive SOAP note for a hypertensive patient should begin with documenting the patient's chief complaint, symptoms, and relevant history. 1

• Chief Complaint: Patient presents for follow-up of hypertension
• History of Present Illness:
  • Duration of hypertension diagnosis
  • Current BP control status
  • Medication adherence/side effects
  • Home BP readings (if available)
  • Symptoms: headaches, visual disturbances, chest pain, shortness of breath, dizziness, nocturia
• Past Medical History:
  • Cardiovascular disease (MI, heart failure, stroke, TIA)
  • Diabetes mellitus
  • Dyslipidemia
  • Chronic kidney disease
• Family History:
  • Hypertension
  • Premature cardiovascular disease
  • Diabetes
  • Hypercholesterolemia
• Social History:
  • Diet (sodium intake, DASH diet adherence)
  • Physical activity level
  • Alcohol consumption
  • Smoking status
  • Psychosocial factors/stress
• Medication History:
  • Current antihypertensive medications with dosages
  • Other medications that may affect BP
  • OTC medications/supplements
  • History of medication intolerances

Objective (O)

• Vital Signs:
  • Blood pressure (measured in both arms, seated position after 5 minutes rest)
  • Heart rate and rhythm
  • Respiratory rate
  • Temperature
  • Weight, height, BMI
• Physical Examination:
  • Cardiovascular: Heart sounds, murmurs, jugular venous distension, peripheral pulses, edema
  • Pulmonary: Breath sounds, crackles
  • Neurological: Mental status, focal deficits
  • Abdominal: Bruits, enlarged kidneys
  • Fundoscopic exam: Retinopathy changes
• Laboratory Data:
  • Complete blood count
  • Comprehensive metabolic panel (electrolytes, renal function)
  • Lipid panel
  • Urinalysis (protein, blood)
  • Hemoglobin A1c (if diabetic)
• Diagnostic Studies:
  • ECG findings
  • Home or ambulatory BP monitoring results
  • Previous imaging studies (echocardiogram, renal ultrasound if applicable)

Assessment (A)

• Primary diagnosis: Hypertension (specify stage based on BP readings)
  • Stage 1: SBP 130-139 mmHg or DBP 80-89 mmHg
  • Stage 2: SBP ≥140 mmHg or DBP ≥90 mmHg 2
• BP control status: Controlled vs. uncontrolled
• Hypertension phenotype: Primary vs. secondary, white coat vs. masked hypertension 1
• Cardiovascular risk assessment: 10-year ASCVD risk score
• Target organ damage assessment:
  • Left ventricular hypertrophy
  • Chronic kidney disease
  • Retinopathy
  • Cerebrovascular disease
• Comorbid conditions: Diabetes, dyslipidemia, obesity, etc.
• Contributing factors: Medication non-adherence, dietary factors, alcohol intake, physical inactivity

Plan (P)

• BP target: <130/80 mmHg for most adults; individualized targets for elderly patients based on frailty and comorbidities 2, 3
• Pharmacological therapy:
  • First-line medications: Thiazide diuretics, ACE inhibitors/ARBs, calcium channel blockers 2, 3
  • Specific medication adjustments (start, continue, increase, decrease, or stop)
  • Medication schedule and dosing instructions
• Lifestyle modifications:
  • DASH diet recommendations
  • Sodium restriction (<2,300 mg/day)
  • Regular physical activity (150 minutes/week moderate-intensity)
  • Weight management goals
  • Alcohol limitation
  • Smoking cessation 2
• Monitoring plan:
  • Home BP monitoring instructions
  • Follow-up appointment timing
  • Laboratory monitoring schedule
• Patient education:
  • Explanation of hypertension as a chronic condition requiring long-term management
  • Importance of medication adherence
  • Recognition of side effects
  • When to seek medical attention 1
• Referrals (if indicated):
  • Cardiology
  • Nephrology
  • Nutrition
  • Secondary hypertension workup

This structured SOAP note format ensures comprehensive documentation and management of hypertensive patients, focusing on accurate diagnosis, risk stratification, and evidence-based treatment planning. 1, 2