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

Example of a SOAP Note for a Patient with Hypertension

A well-structured SOAP note is essential for documenting hypertension care and should include comprehensive assessment, clear treatment goals, and a specific follow-up plan based on current guidelines. 1

Subjective

• Chief complaint: "My blood pressure has been high lately" or "Here for blood pressure check"
• History of present illness:
  • Duration of hypertension
  • Current symptoms (headache, dizziness, visual disturbances, chest pain, shortness of breath)
  • Home BP readings and patterns (morning vs. evening)
  • Current antihypertensive medications and adherence
  • Last medication adjustment
• Past medical history:
  • Cardiovascular risk factors (diabetes, hyperlipidemia, smoking)
  • Previous cardiovascular events (MI, stroke)
  • Kidney disease
  • Sleep apnea
• Medications:
  • All current medications with doses and frequency
  • OTC medications (NSAIDs, decongestants)
  • Supplements
• Social history:
  • Smoking status
  • Alcohol intake (quantify)
  • Exercise habits
  • Dietary patterns (sodium intake, DASH diet adherence)
  • Stress levels
• Family history:
  • Hypertension
  • Cardiovascular disease
  • Stroke
  • Kidney disease

Objective

• Vital signs:
  • Blood pressure (measured in both arms, note position)
  • Heart rate
  • Respiratory rate
  • Temperature
  • Weight, height, BMI
• Physical examination:
  • Cardiovascular: Heart sounds, murmurs, JVD, peripheral pulses
  • Pulmonary: Breath sounds, crackles
  • Abdominal: Bruits, masses
  • Extremities: Edema
  • Neurological: Focal deficits
  • Fundoscopic exam: Retinopathy changes
• Laboratory data:
  • Basic metabolic panel (electrolytes, creatinine, eGFR)
  • Urinalysis (protein)
  • Lipid panel
  • Hemoglobin A1c (if diabetic)
  • ECG findings
• Home BP monitoring data (if available)

Assessment

• Hypertension classification (based on ACC/AHA guidelines):
  • Normal BP (<120/80 mmHg)
  • Elevated BP (120-129/<80 mmHg)
  • Stage 1 Hypertension (130-139/80-89 mmHg)
  • Stage 2 Hypertension (≥140/90 mmHg) 1
• Controlled vs. uncontrolled hypertension
• Target organ damage assessment:
  • Left ventricular hypertrophy
  • Retinopathy
  • Chronic kidney disease
  • Cerebrovascular disease
• Cardiovascular risk assessment
• Medication effectiveness and adherence
• Lifestyle modification assessment
• Secondary causes of hypertension (if suspected)

Plan

• Blood pressure goal: Specify target BP (typically <130/80 mmHg for most adults) 1
• Pharmacological therapy:
  • Continue current regimen if effective
  • Medication adjustments (specific doses)
  • First-line options: thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers 1, 2
  • For specific populations (e.g., ACE inhibitors/ARBs for diabetic patients) 1
• Lifestyle modifications:
  • Sodium restriction (<2,300 mg/day)
  • DASH diet
  • Physical activity (90-150 minutes/week)
  • Weight loss goals (if applicable)
  • Alcohol limitation (≤1 drink/day for women, ≤2 drinks/day for men) 1
• Monitoring plan:
  • Home BP monitoring instructions
  • Frequency of readings
  • Documentation method
• Laboratory monitoring:
  • Electrolytes and kidney function (especially if on diuretics, ACE inhibitors, or ARBs)
  • Other tests as indicated
• Follow-up:
  • Next appointment (typically monthly until BP controlled) 1
  • When to contact provider (BP thresholds, symptoms)
• Education:
  • Medication instructions
  • BP monitoring technique
  • Recognition of emergency symptoms
  • Importance of adherence

This structured SOAP note format ensures comprehensive documentation of hypertension management according to current clinical guidelines and facilitates consistent, evidence-based care for patients with hypertension.