Cardiology: Step-by-Step Guide on How to Write SOAP Notes
Updated January 2026
Cardiology documentation demands precision, thoroughness, and adherence to evidence-based guidelines. Cardiovascular SOAP notes must capture complex diagnostic workups, risk stratification, and multifaceted treatment regimens. This guide provides comprehensive instructions for documenting cardiology encounters, from routine follow-ups to acute cardiac events, ensuring compliance with ACC/AHA guidelines and optimal patient care.
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Unique Aspects of Cardiology Documentation
Cardiology documentation differs from other specialties in several key ways:
- Risk Stratification: Documentation must support cardiovascular risk assessment using validated tools (ASCVD, HEART, CHA2DS2-VASc)
- Complex Diagnostics: Integration of ECG, echocardiography, stress testing, and catheterization findings
- Guideline-Directed Medical Therapy (GDMT): Must demonstrate adherence to ACC/AHA treatment guidelines
- Device Management: Pacemaker and ICD documentation requirements
- Longitudinal Care: Tracking ejection fraction, functional status, and medication titration over time
- Procedural Documentation: Detailed documentation for catheterization, ablation, and device procedures
- Anticoagulation Management: Careful documentation of bleeding vs. thrombotic risk assessment
Subjective Section (S)
The Subjective section in cardiology captures symptom characterization, functional status assessment, and cardiac risk factors essential for diagnosis and risk stratification.
Subjective Section (S) Components
-
Chief Complaint:
- Primary cardiac symptom with duration
- Urgency and acuity level
- Example: "Exertional chest discomfort x 3 weeks, progressive"
-
Chest Pain Characterization:
- Location, quality, duration, radiation
- Precipitating factors (exertion, rest, meals, position)
- Relieving factors (rest, nitroglycerin)
- Associated symptoms (dyspnea, diaphoresis, nausea)
- Typical vs. atypical features
- Example: "Substernal pressure radiating to left arm, provoked by climbing stairs, relieved with rest. Associated with dyspnea."
-
Dyspnea Classification (NYHA Functional Class):
- Class I: No limitation of physical activity
- Class II: Slight limitation; comfortable at rest, symptoms with ordinary activity
- Class III: Marked limitation; comfortable at rest, symptoms with less than ordinary activity
- Class IV: Unable to carry on any physical activity without symptoms; symptoms at rest
- Example: "Patient reports dyspnea with one flight of stairs, comfortable at rest - NYHA Class II"
-
Palpitations:
- Onset, frequency, duration
- Regular vs. irregular rhythm
- Associated symptoms (presyncope, syncope, chest pain)
- Triggers (caffeine, alcohol, stress, exercise)
- Example: "Intermittent rapid irregular palpitations lasting 10-30 minutes, occurring 2-3x weekly, associated with lightheadedness"
-
Syncope/Presyncope:
- Prodrome (lightheadedness, vision changes, nausea)
- Circumstances (exertional, positional, situational)
- Witness account if available
- Post-event symptoms
- Example: "Episode of witnessed syncope during exercise, no prodrome, brief loss of consciousness with rapid recovery"
-
Cardiac Risk Factors:
- Hypertension (duration, control, medications)
- Diabetes mellitus (HbA1c, complications)
- Hyperlipidemia (current lipid panel, statin use)
- Tobacco use (pack-years, cessation status)
- Family history of premature CAD (males under 55, females under 65)
- Obesity (BMI, distribution)
- Physical inactivity
- Example: "HTN x 15 years on 3 agents, DM2 with HbA1c 7.8%, former smoker (30 pack-years, quit 2020)"
-
Current Cardiac Medications:
- Antiplatelets/anticoagulants
- Beta-blockers (heart rate response)
- ACE-I/ARB/ARNI
- Statins (intensity)
- Diuretics (weight monitoring)
- Antiarrhythmics
- Document adherence and side effects
-
Device Status (if applicable):
- Pacemaker/ICD symptoms
- Shocks delivered
- Last interrogation date
Example Subjective Section for Cardiology
Subjective (Cardiology)
CHIEF COMPLAINT: Worsening exertional dyspnea and fatigue x 4 weeks
HISTORY OF PRESENT ILLNESS:
68-year-old male with known ischemic cardiomyopathy (EF 35% on last echo 6 months ago) and prior anterior MI (2021, PCI to LAD) presents for evaluation of progressive exertional dyspnea over the past 4 weeks.
SYMPTOMS:
- Dyspnea: Previously able to walk 4 blocks, now limited to 1 block
- NYHA Functional Class: III (previously II)
- Orthopnea: Now requiring 3 pillows (previously 2)
- PND: 2-3 episodes per week, awakening with dyspnea after 2-3 hours of sleep
- Lower extremity edema: Bilateral ankle swelling, worse at end of day
- Weight gain: +8 lbs over past 3 weeks despite dietary compliance
- Fatigue: Significantly limiting daily activities
- Denies chest pain, palpitations, or syncope
CHEST PAIN ASSESSMENT: No anginal symptoms since revascularization in 2021
PALPITATIONS: Occasional awareness of irregular heartbeat, non-sustained
SYNCOPE/PRESYNCOPE: Denies
CARDIAC RISK FACTORS:
- Hypertension: Diagnosed 20 years ago, currently on lisinopril 40mg, amlodipine 10mg
- Type 2 diabetes: 15 years, HbA1c 7.4% (last month), on metformin and empagliflozin
- Hyperlipidemia: On atorvastatin 80mg, last LDL 68 mg/dL
- Former smoker: 40 pack-years, quit 2021 after MI
- Family history: Father MI at age 58, died age 62; brother with CAD
- BMI: 31.2 kg/m2
PAST CARDIAC HISTORY:
- Anterior STEMI (2021) with PCI/DES to mid-LAD
- Ischemic cardiomyopathy, EF 35% (June 2025 echo)
- ICD implanted 2022 for primary prevention
- Paroxysmal atrial fibrillation (rate controlled, on anticoagulation)
- Last cardiac catheterization: 2023 - patent LAD stent, 60% RCA stenosis
CURRENT MEDICATIONS:
- Aspirin 81mg daily
- Apixaban 5mg BID (for AFib)
- Carvedilol 25mg BID (HR today 68, previously on higher dose limited by hypotension)
- Sacubitril-valsartan 97/103mg BID
- Spironolactone 25mg daily
- Empagliflozin 10mg daily
- Atorvastatin 80mg daily
- Furosemide 40mg daily (recently increased from 20mg)
- Metformin 1000mg BID
ALLERGIES: Lisinopril (cough)
ICD STATUS: Last interrogation 2 months ago - no therapies delivered, AF burden 12%
ADHERENCE: Good medication adherence, reports taking all medications as prescribed
DIET: Attempting low-sodium diet, admits to occasional dietary indiscretion
FLUID INTAKE: Limiting to 2L daily
SOCIAL HISTORY:
- Retired teacher
- Lives with wife, supportive home environment
- No alcohol since MI, no tobacco since 2021
- Sedentary due to functional limitation
Objective Section (O)
The cardiology Objective section requires comprehensive cardiovascular examination, hemodynamic assessment, and integration of diagnostic studies.
Objective Section (O) Components
-
Vital Signs Including Orthostatics:
- Blood pressure (both arms if indicated, sitting and standing)
- Heart rate and rhythm
- Respiratory rate
- Oxygen saturation
- Weight (critical for heart failure)
- BMI
- Example: "BP sitting 118/72, standing 98/64; HR 68 regular; SpO2 94% RA; Weight 198 lbs (+8 from baseline)"
-
General Appearance:
- Volume status assessment
- Respiratory distress
- Cardiac cachexia if present
-
Jugular Venous Pressure (JVP):
- Height above sternal angle
- Waveform abnormalities (cannon A waves, V waves)
- Hepatojugular reflux
- Example: "JVP elevated to 12 cm H2O with positive hepatojugular reflux"
-
Cardiac Examination:
- Inspection: Visible apical impulse, precordial heave
- Palpation: PMI (location, size, character), thrills
- Auscultation:
- Heart sounds (S1, S2 quality and splitting)
- S3 (ventricular gallop) - heart failure indicator
- S4 (atrial gallop) - reduced compliance
- Murmurs (timing, location, grade, radiation, maneuvers)
- Rubs (pericarditis)
- Example: "PMI laterally displaced to 6th ICS, AAL. S1 normal, S2 with physiologic split, S3 gallop present. Grade 2/6 holosystolic murmur at apex radiating to axilla."
-
Peripheral Vascular Examination:
- Peripheral pulses (radial, femoral, DP, PT)
- Peripheral edema (location, severity, pitting)
- Skin temperature and color
- Capillary refill
- Example: "Bilateral 2+ pitting edema to mid-calf. Pulses 2+ throughout. Warm extremities."
-
Pulmonary Examination:
- Breath sounds
- Crackles/rales (location, extent)
- Wheezing
- Pleural effusion signs
-
ECG Interpretation:
- Rate, rhythm, axis
- Intervals (PR, QRS, QT/QTc)
- Atrial abnormalities
- Ventricular hypertrophy
- ST-T wave changes
- Q waves
- Comparison to prior
-
Echocardiogram Findings:
- LV size and function (EF, wall motion)
- RV size and function
- Valvular assessment
- Diastolic function
- Pericardium
- Estimated pressures (RVSP)
-
Laboratory Results:
- BNP/NT-proBNP
- Troponin
- Basic metabolic panel (electrolytes, renal function)
- CBC
- Lipid panel
- HbA1c
- Thyroid function
-
Device Interrogation (if applicable):
- Battery status
- Lead parameters
- Arrhythmia episodes
- Therapy delivery
Example Objective Section for Cardiology
Objective (Cardiology)
VITAL SIGNS:
- Blood Pressure: 118/72 mmHg (sitting, right arm); 98/64 mmHg (standing - orthostatic drop)
- Heart Rate: 68 bpm, irregularly irregular
- Respiratory Rate: 20 breaths/min
- SpO2: 94% on room air
- Temperature: 98.2°F
- Weight: 198 lbs (89.8 kg) - UP 8 lbs from baseline 4 weeks ago
- Height: 5'10' (178 cm)
- BMI: 28.4 kg/m2
GENERAL APPEARANCE:
Alert, pleasant male in no acute distress at rest. Mild respiratory effort with conversation. No cardiac cachexia. Well-nourished.
NECK:
- JVP: Elevated to 12 cm H2O (measured at 45 degrees)
- Hepatojugular reflux: Positive
- Carotid pulses: 2+ bilaterally without bruits
- No thyromegaly or lymphadenopathy
CARDIOVASCULAR EXAMINATION:
- Inspection: No visible heave or apical impulse
- Palpation: PMI laterally displaced to 6th intercostal space, anterior axillary line; diffuse and sustained. No thrills.
- Auscultation:
- Rate/Rhythm: Irregularly irregular
- S1: Normal intensity
- S2: Normal physiologic splitting, P2 mildly accentuated
- S3: Present (ventricular gallop) - indicative of elevated filling pressures
- S4: Absent
- Murmurs: Grade 2/6 holosystolic murmur at apex, radiating to axilla (consistent with mitral regurgitation)
- No rubs or clicks
PULMONARY:
- Respiratory effort: Mildly increased
- Breath sounds: Bibasilar crackles extending 1/3 up lung fields bilaterally
- No wheezes or rhonchi
- Dullness to percussion at right base (possible small pleural effusion)
ABDOMEN:
- Soft, non-tender, mildly distended
- Liver: Palpable 2 cm below right costal margin, mildly tender
- No ascites appreciated
- Normal bowel sounds
EXTREMITIES:
- Bilateral 2+ pitting edema to mid-calf (increased from trace edema at last visit)
- No calf tenderness or asymmetry
- Warm, well-perfused
- No clubbing or cyanosis
PERIPHERAL PULSES:
- Radial: 2+ bilaterally
- Femoral: 2+ bilaterally
- Dorsalis pedis: 1+ bilaterally (diminished from baseline)
- Posterior tibial: 1+ bilaterally
SKIN: No rashes, dry skin on lower extremities
NEUROLOGICAL: Alert and oriented x 4, no focal deficits
ECG (today):
- Rate: 72 bpm (average ventricular rate)
- Rhythm: Atrial fibrillation
- Axis: Left axis deviation (-35 degrees)
- Intervals: QRS 112 ms, QTc 468 ms
- P waves: Absent (fibrillatory waves)
- QRS: Q waves in V1-V3 (prior anterior MI)
- ST-T: No acute ST changes, T-wave inversions in V1-V3 (unchanged)
- LVH: Voltage criteria not met
- Comparison: Similar to ECG from 3 months ago, rate slightly higher
- INTERPRETATION: Atrial fibrillation with controlled ventricular response, left axis deviation, evidence of prior anterior MI
ECHOCARDIOGRAM (today - portable):
- LV size: Mildly dilated (LVIDd 5.8 cm)
- LV function: LVEF 30-35% (reduced from 35% six months ago)
- Wall motion: Akinesis of mid-distal anterior wall and apex (prior MI territory); global hypokinesis
- RV size and function: Mildly dilated, mildly reduced function (TAPSE 15 mm)
- Left atrium: Moderately dilated (4.6 cm)
- Right atrium: Mildly dilated
- Mitral valve: Moderate mitral regurgitation (MR), central jet, secondary to annular dilation
- Tricuspid valve: Mild TR
- Aortic valve: Trileaflet, no stenosis, trace AR
- Pulmonic valve: Normal
- RVSP: Elevated at 48 mmHg (normal <35)
- IVC: Dilated (2.4 cm) with <50% inspiratory collapse (elevated RA pressure)
- Pericardium: No effusion
- COMPARISON: EF reduced from 35% to 30-35%; new moderate MR (previously mild); RVSP increased
LABORATORY RESULTS (today):
- BNP: 1,842 pg/mL (elevated, up from 580 pg/mL 3 months ago)
- Troponin I: 0.04 ng/mL (at upper limit, stable)
- BMP: Na 132 (L), K 4.8, Cl 98, CO2 22 (L), BUN 38 (H), Cr 1.6 (H, baseline 1.2), Glucose 142
- Magnesium: 1.8 mg/dL
- CBC: WBC 7.2, Hgb 11.8 (L), Hct 35.4, Plt 198
- Hepatic panel: AST 42 (H), ALT 48 (H), Alk Phos 112, Total Bili 1.4 (H)
- Lipid panel (fasting): Total cholesterol 158, LDL 62, HDL 38, TG 168
- HbA1c: 7.4%
- TSH: 2.4 mIU/L (normal)
- Urinalysis: Specific gravity 1.025, no protein
ICD INTERROGATION (today):
- Device: Boston Scientific ICD (implant 2022)
- Battery: Adequate (estimated longevity 4.5 years)
- RV lead: Threshold 0.75V @ 0.4ms, Impedance 480 ohms, R-wave 11.2 mV
- Atrial lead: Threshold 1.0V @ 0.4ms, Impedance 420 ohms, P-wave 2.8 mV
- Arrhythmia log: AF burden 28% (increased from 12%), multiple NSVT episodes (longest 8 beats), no sustained VT/VF, no therapies delivered
- Mode: DDD 60-130, AV delay 180ms
- AF mode switch: Appropriately functioning
Assessment Section (A)
The cardiology Assessment synthesizes clinical findings, provides risk stratification, and documents guideline-directed reasoning.
Assessment Section (A) Components
-
Primary Diagnosis:
- ICD-10 code
- Severity/stage classification (e.g., ACC/AHA Stage C HFrEF)
-
Cardiovascular Risk Assessment:
- ASCVD 10-year risk score (for primary prevention)
- HEART score (for acute chest pain)
- CHA2DS2-VASc score (for atrial fibrillation)
- HAS-BLED score (for bleeding risk)
-
Guideline References:
- ACC/AHA heart failure guidelines
- ACC/AHA/ESC arrhythmia guidelines
- ACC/AHA chest pain guidelines
- Lipid management guidelines
-
Clinical Reasoning:
- Integration of symptoms, exam, and diagnostic findings
- Differential diagnosis when applicable
- Disease progression assessment
-
GDMT Assessment:
- Current medications relative to guideline recommendations
- Target doses achieved or barriers
- Optimization opportunities
Example Assessment Section for Cardiology
Assessment (Cardiology)
ASSESSMENT:
1. ACUTE DECOMPENSATED HEART FAILURE (I50.23)
ACC/AHA Stage C, NYHA Class III (worsened from Class II)
- Clinical evidence of decompensation:
- Symptoms: Progressive dyspnea, orthopnea, PND, weight gain (+8 lbs)
- Exam: Elevated JVP (12 cm), S3 gallop, bibasilar crackles, hepatomegaly, 2+ peripheral edema
- Labs: BNP markedly elevated at 1,842 pg/mL (from baseline 580)
- Echo: EF declined to 30-35% (from 35%), elevated RVSP, dilated IVC
- Precipitating factors to consider:
- Increased AF burden (28% vs 12%) with possible tachycardia-mediated contribution
- Dietary indiscretion (patient admits occasional sodium intake)
- Worsening renal function limiting diuretic efficacy
- Disease progression
- Medication compliance confirmed - not a factor
- Congestion profile: Wet (elevated JVP, edema, crackles)
- Perfusion profile: Warm (adequate BP, warm extremities, mentating well)
- Profile: 'Warm and Wet' - requires diuresis
2. ISCHEMIC CARDIOMYOPATHY (I25.5)
- EF 30-35% with anterior wall akinesis (prior LAD MI territory)
- EF declined from 35% on prior echo (6 months ago)
- Currently on optimal GDMT (see below)
- ICD in place for primary prevention
3. PAROXYSMAL ATRIAL FIBRILLATION (I48.0)
- Currently in AF on today's ECG and exam
- Rate controlled (HR 68-72)
- AF burden increased to 28% per ICD interrogation (previously 12%)
- Increased AF burden may be contributing to HF decompensation
- Anticoagulation: On apixaban 5mg BID
- CHA2DS2-VASc score: 5 (CHF 1, HTN 1, Age 1, DM 1, Vascular disease 1) - HIGH stroke risk, anticoagulation indicated
- HAS-BLED score: 2 (HTN, Age) - moderate bleeding risk, anticoagulation benefits outweigh risks
4. SECONDARY MITRAL REGURGITATION (I34.0)
- Moderate MR (new, previously mild)
- Secondary to LV dilation and annular dilation
- Contributing to elevated left-sided filling pressures
- Consider referral for TEER evaluation if MR persists after optimization
5. WORSENING RENAL FUNCTION - CARDIORENAL SYNDROME TYPE 1 (N17.9)
- Creatinine 1.6 (baseline 1.2) - worsened in setting of HF decompensation
- Likely cardiorenal syndrome given volume overload and venous congestion
- Expect improvement with effective decongestion
6. CORONARY ARTERY DISEASE (I25.10)
- Prior anterior STEMI (2021) with PCI/DES to LAD
- Known 60% RCA stenosis (2023 cath) - medically managed
- No current anginal symptoms
- On appropriate secondary prevention (aspirin, high-intensity statin, beta-blocker)
7. TYPE 2 DIABETES MELLITUS (E11.9)
- HbA1c 7.4% - at goal for patient with cardiovascular disease
- On empagliflozin (SGLT2i) with cardiovascular and HF benefit
- On metformin - may need to hold if renal function worsens further
8. HYPERTENSION (I10)
- Currently normotensive/hypotensive (orthostatic drop)
- Limitation to uptitrating HF medications
9. HYPERLIPIDEMIA (E78.5)
- LDL 62 mg/dL - at goal (<70 for very high-risk ASCVD)
- On high-intensity statin (atorvastatin 80mg)
GUIDELINE-DIRECTED MEDICAL THERAPY (GDMT) ASSESSMENT:
Per 2022 AHA/ACC/HFSA Guidelines for Heart Failure:
| GDMT Class | Current Regimen | Target Dose | Status |
|------------|-----------------|-------------|--------|
| ARNI | Sacubitril-valsartan 97/103mg BID | 97/103mg BID | AT TARGET |
| Beta-blocker | Carvedilol 25mg BID | 25mg BID | AT TARGET (limited by BP) |
| MRA | Spironolactone 25mg daily | 25-50mg daily | AT TARGET |
| SGLT2i | Empagliflozin 10mg daily | 10mg daily | AT TARGET |
| Loop diuretic | Furosemide 40mg daily | As needed | REQUIRES UPTITRATION |
Assessment: Patient on 4-pillar GDMT at or near target doses. Beta-blocker and ARNI at maximum tolerated due to blood pressure. Diuretic requires intensification for decongestion.
Plan Section (P)
The cardiology Plan must address acute interventions, medication optimization, procedures, lifestyle modifications, and follow-up consistent with ACC/AHA guidelines.
Plan Section (P) Components
-
Acute Interventions:
- Diuretic adjustments
- IV therapy if indicated
- Monitoring parameters
-
Cardiac Medications:
- GDMT optimization
- Dosage adjustments with rationale
- New medications with indication
- Medications held and reason
-
Procedures:
- Catheterization, ablation, device procedures
- Pre-procedure planning
- Post-procedure care
-
Lifestyle Modifications:
- Sodium restriction
- Fluid restriction
- Weight monitoring
- Exercise/cardiac rehab
- Smoking cessation
- Alcohol limitation
-
Cardiac Rehabilitation:
- Referral criteria
- Phase specification
- Goals
-
Monitoring Plan:
- Labs (BNP, renal function, electrolytes)
- Daily weights
- Telemonitoring devices
- ICD remote monitoring
-
Specialist Consultations:
- Electrophysiology
- Heart failure specialist
- Cardiac surgery
- Palliative care (if appropriate)
-
Follow-up:
- Timing and focus of next visit
- Parameters for urgent return
Example Plan Section for Cardiology
Plan (Cardiology)
PLAN:
1. ACUTE DECOMPENSATED HEART FAILURE:
Diuresis Strategy:
- Increase furosemide to 80mg PO BID (up from 40mg daily)
- Add metolazone 2.5mg PO daily x 3 days for diuretic synergy
- Target: 2-3 L net negative daily, goal weight loss 8-10 lbs to dry weight
- Monitor daily weights, strict I/Os, daily BMP for renal function and electrolytes
If inadequate response in 48-72 hours:
- Consider IV diuretics (furosemide 80mg IV BID)
- May require hospitalization if unable to achieve adequate diuresis outpatient
Fluid and Sodium Restriction:
- Sodium: <2 grams daily (counseled patient and wife)
- Fluid: 1.5-2L daily restriction
Daily Weight Protocol:
- Weigh daily, same time, same scale, after voiding
- Call if weight increases >3 lbs in 24 hours or >5 lbs in 1 week
2. ISCHEMIC CARDIOMYOPATHY - GDMT:
Continue current GDMT at target doses:
- Sacubitril-valsartan 97/103mg BID - continue (at target)
- Carvedilol 25mg BID - continue (at maximum tolerated, limited by BP/orthostasis)
- Spironolactone 25mg daily - continue (monitor K+ closely with diuresis)
- Empagliflozin 10mg daily - continue (provides HF and renal benefit)
Medication Adjustments:
- Aspirin 81mg daily - continue for CAD secondary prevention
- Atorvastatin 80mg daily - continue (LDL at goal)
Metformin: HOLD temporarily due to worsening renal function (Cr 1.6)
- Reassess when Cr improves with decongestion
3. ATRIAL FIBRILLATION:
Rate Control:
- Current rate well-controlled on carvedilol
- No adjustment needed
Anticoagulation:
- Continue apixaban 5mg BID
- CHA2DS2-VASc 5 (high risk) - anticoagulation strongly indicated
- HAS-BLED 2 - acceptable bleeding risk
Rhythm Control Consideration:
- AF burden increased to 28%; may be contributing to HF decompensation
- Discuss catheter ablation with EP for rhythm control to reduce AF burden
- Consider amiodarone if ablation not pursued (pending EP evaluation)
- Order EP consultation
4. SECONDARY MITRAL REGURGITATION:
- Repeat echo after decongestion to reassess MR severity
- If moderate or greater MR persists on optimal GDMT:
- Refer for evaluation for transcatheter edge-to-edge repair (TEER/MitraClip)
- Patient may meet COAPT trial criteria
5. WORSENING RENAL FUNCTION:
- Hold metformin until Cr improves
- Continue SGLT2i (renoprotective)
- Monitor BMP daily during intensive diuresis
- Acceptable Cr rise with effective diuresis (decongestion improves renal perfusion)
- If Cr rises >0.5 from baseline, reassess diuretic strategy
6. ICD MANAGEMENT:
- Continue current programming
- Increased NSVT burden noted - reassess after volume optimization
- Remote monitoring: Ensure patient enrolled in home monitoring
- Next routine interrogation: 3 months or sooner if symptoms
7. CARDIAC REHABILITATION:
- Referral to Phase 2 cardiac rehabilitation program
- Benefits: Improved functional capacity, quality of life, reduced hospitalizations
- To begin after stabilization from current decompensation
8. LIFESTYLE COUNSELING:
- Sodium restriction: <2g daily - provided written dietary guidance
- Fluid restriction: 1.5-2L daily
- Daily weights: Emphasized importance
- Exercise: Light activity as tolerated; no strenuous exercise until stable
- Smoking: Continue abstinence (quit 2021) - positive reinforcement
- Alcohol: Complete abstinence recommended given cardiomyopathy
9. LABORATORY MONITORING:
- BMP: Daily x 3 days (may do at local lab), then every 2-3 days during intensive diuresis
- Potassium and magnesium: Monitor closely with increased diuretics; supplement PRN
- BNP: Recheck in 1 week to assess response
- CBC, hepatic panel: Recheck in 1 week
10. CONSULTATIONS:
- Electrophysiology: For AF ablation evaluation given increased AF burden
- Advanced Heart Failure (if no improvement): Discuss advanced therapies if continues to decline
- Nutritionist: Reinforce low-sodium diet education
11. FOLLOW-UP:
- Phone check: 48-72 hours for weight, symptoms, lab review
- Office visit: 1 week for reassessment
- Call clinic immediately for: Weight gain >3 lbs in 24 hours, worsening dyspnea, chest pain, presyncope/syncope, ICD shocks
12. DISPOSITION: Home with close outpatient follow-up
- Decision for hospitalization: If inadequate response to oral diuretics, worsening renal function, hypotension, or clinical deterioration
PATIENT EDUCATION PROVIDED:
- Explained findings of heart failure decompensation
- Reviewed medication changes and rationale
- Emphasized daily weights, sodium restriction, fluid restriction
- Discussed warning signs requiring immediate medical attention
- Patient and wife verbalize understanding
FOLLOW-UP APPOINTMENT: 1 week - Heart Failure Clinic
AI-Assisted Documentation for Cardiology
As of 2025, 66% of healthcare providers utilize AI tools in their practice. AI scribes and ambient clinical intelligence can significantly reduce documentation burden for cardiologists while maintaining comprehensive records.
How AI Can Help with Cardiology Documentation
- Symptom capture: Accurately documents chest pain characterization, dyspnea classification, and symptom progression
- Medication reconciliation: Captures complex cardiac medication regimens with doses
- Exam findings: Documents cardiac examination including murmur grading
- Risk score calculation: Can assist with ASCVD, CHA2DS2-VASc, and other calculations
- Template generation: Creates structured notes based on clinical conversation
Cardiology-Specific AI Considerations
What AI captures well:
- Symptom history and HPI details
- NYHA functional class from patient description
- Medication lists and adherence
- Lifestyle discussion (diet, exercise, smoking)
- Follow-up instructions
What requires careful review:
- ECG interpretation: Verify AI-captured ECG findings against your read
- Murmur grading: Confirm grade, timing, and radiation accuracy
- Echo measurements: Verify EF percentages and valve findings
- Vital signs with orthostatics: Ensure positional changes captured
- Device interrogation data: Verify specific parameters and arrhythmia logs
- Complex medication regimens: Double-check doses, especially anticoagulants
Tips for Using AI with Cardiology Documentation
- Verbalize examination findings clearly: "There is an S3 gallop present" not "S3"
- State measurements precisely: "JVP is elevated to 12 centimeters" not "JVP up"
- Dictate ECG findings systematically: "Rate 72, rhythm atrial fibrillation, axis left, Q waves in V1 through V3"
- Specify murmur characteristics: "Grade 2 out of 6 holosystolic murmur at the apex radiating to the axilla"
- Review device data carefully: AI may not accurately capture complex ICD interrogation findings
- Verify guideline-directed therapy assessment: Confirm GDMT status is accurately documented
AI-Assisted Cardiology Documentation Checklist
AI DOCUMENTATION REVIEW CHECKLIST - CARDIOLOGY
Before signing AI-generated notes, verify:
VITAL SIGNS:
[ ] Blood pressure values and orthostatic changes
[ ] Heart rate and rhythm accuracy
[ ] Weight and weight change from baseline
EXAMINATION:
[ ] JVP measurement (cm H2O)
[ ] S3/S4 presence or absence
[ ] Murmur grade, timing, location, radiation
[ ] Edema severity and location
[ ] Pulmonary findings (crackles, location)
DIAGNOSTICS:
[ ] ECG interpretation matches your read
[ ] Echo EF percentage and wall motion
[ ] Lab values, especially BNP and troponin
[ ] Device interrogation parameters
ASSESSMENT:
[ ] NYHA class correctly captured
[ ] ICD-10 codes accurate
[ ] Risk scores calculated correctly
[ ] GDMT status accurately documented
PLAN:
[ ] Medication doses correct
[ ] Anticoagulation dose verified
[ ] Follow-up timing accurate
[ ] Warning signs documented
For more details, see our complete AI-Assisted Documentation Guide.
Telehealth Cardiology Documentation
Virtual cardiology care has expanded significantly, particularly for chronic disease management, medication adjustments, and device follow-up. Per CMS 2026 guidelines, telehealth services continue with specific documentation requirements.
Telehealth-Specific Cardiology Services
-
Remote Patient Monitoring (RPM):
- Daily weight monitoring
- Blood pressure monitoring
- Heart rate monitoring
- Implanted device data transmission
-
Device Remote Interrogation:
- Pacemaker/ICD remote checks
- Cardiac implantable electronic device (CIED) monitoring
- Alert-based reviews
-
Chronic Disease Management:
- Heart failure follow-up
- Atrial fibrillation management
- Hypertension optimization
- Anticoagulation management
Telehealth Cardiology Documentation Requirements
For virtual cardiology visits, document:
-
Visit logistics:
- Platform used (HIPAA-compliant)
- Patient and provider locations
- Consent for telehealth services
-
Remote monitoring data integration:
- Weight trends from home scale
- BP trends from home monitoring
- Device transmission data
-
Modified examination:
- Patient self-assessment (edema, dyspnea)
- Visual assessment (general appearance, JVD if visible)
- Functional assessment via observation
-
Examination limitations:
- Document what could not be assessed
- Indicate when in-person visit is needed
Example Telehealth Cardiology Documentation
Telehealth Cardiology Documentation Example
TELEHEALTH VISIT - CARDIOLOGY
SESSION DETAILS:
- Platform: Doxy.me (HIPAA-compliant video)
- Patient Location: Home in California
- Provider Location: Cardiology Clinic, California
- Consent: Patient verbally consented to telehealth cardiology visit
- Visit type: Heart Failure Follow-Up
REMOTE MONITORING DATA (past 7 days):
- Weight: 192 lbs today (baseline 190, peak 198 last week) - DOWN 6 lbs with diuresis
- Weight trend: Declining appropriately toward dry weight
- Blood pressure (average): 112/68 mmHg
- Heart rate (average): 72 bpm
- ICD remote transmission (yesterday):
- No arrhythmia alerts
- AF burden: 15% (improved from 28%)
- No ventricular arrhythmias or therapies
SUBJECTIVE (via video):
Patient reports significant improvement in symptoms over past week on increased diuretics.
- Dyspnea: Improved - now able to walk 2 blocks (up from 1 block)
- Orthopnea: Reduced to 2 pillows (from 3)
- PND: Resolved - no episodes this week
- Edema: Patient reports ankle swelling much improved
- Energy: Improving
- Denies chest pain, palpitations, ICD shocks, or presyncope
- Tolerating medications well, no dizziness despite increased diuretics
- Adherent to 2g sodium diet this week
OBJECTIVE (Modified for Telehealth):
General: Alert, comfortable appearing, in no respiratory distress. Speaking in full sentences without dyspnea.
Video assessment:
- No visible JVD (difficult to fully assess via video)
- Facial color appears normal, no pallor
- No visible respiratory distress
- Patient demonstrates ankle area via video - trace edema visible (improved from prior)
- Movement: Patient demonstrated standing from sitting without difficulty
TELEHEALTH LIMITATIONS:
Unable to perform via telehealth: Auscultation (heart sounds, murmur assessment, lung sounds), accurate JVP measurement, detailed edema assessment, orthostatic vitals. In-person visit scheduled for next week for complete cardiac examination and repeat echo.
ASSESSMENT:
1. Acute on chronic heart failure exacerbation - IMPROVING
- Significant clinical improvement with intensified diuresis
- Weight down 6 lbs from peak, approaching dry weight
- Symptoms improved, NYHA Class II (from Class III)
- AF burden improved per remote ICD monitoring
- Will continue current regimen
2. Paroxysmal atrial fibrillation - improved control
- AF burden down to 15% from 28%
- Rate controlled on current beta-blocker dose
PLAN:
1. Continue furosemide 80mg BID x 3 more days, then reassess
2. Continue metolazone 2.5mg daily through end of week, then stop
3. Continue all other GDMT medications at current doses
4. Daily weights - call if >3 lb gain
5. Recheck BMP and BNP at local lab tomorrow
6. Dietary compliance: Continue <2g sodium, 1.5L fluid restriction
7. In-person visit: Scheduled 1 week for complete cardiac exam, echo reassessment
8. EP referral: Pending - will discuss AF ablation at in-person visit
9. Call clinic for: Weight gain, worsening dyspnea, chest pain, ICD shocks
Next telehealth check: 3 days to review labs
Next in-person visit: 1 week
Device Remote Monitoring Documentation
ICD Remote Monitoring Note Template
CARDIAC DEVICE REMOTE MONITORING
DEVICE INFORMATION:
- Device type: [Pacemaker/ICD/CRT-D/CRT-P]
- Manufacturer: [Boston Scientific/Medtronic/Abbott]
- Model:
- Implant date:
- Indication:
TRANSMISSION DETAILS:
- Transmission date:
- Transmission type: [ ] Scheduled [ ] Alert-triggered [ ] Patient-initiated
- Time since last transmission:
BATTERY STATUS:
- Voltage:
- Estimated longevity:
- Status: [ ] Adequate [ ] ERI [ ] EOL
LEAD PARAMETERS:
Atrial lead (if applicable):
- Threshold: ___ V @ ___ ms
- Impedance: ___ ohms
- Sensing: ___ mV
- Status: [ ] Stable [ ] Changed
RV lead:
- Threshold: ___ V @ ___ ms
- Impedance: ___ ohms
- R-wave sensing: ___ mV
- Status: [ ] Stable [ ] Changed
LV lead (if CRT):
- Threshold: ___ V @ ___ ms
- Impedance: ___ ohms
- Status: [ ] Stable [ ] Changed
ARRHYTHMIA EPISODES:
- Atrial arrhythmias: [ ] None [ ] AF/AFL burden: ___%
- Ventricular arrhythmias: [ ] None [ ] PVCs: ___% [ ] NSVT: ___ episodes [ ] VT/VF: ___
- Mode switches: ___
THERAPIES DELIVERED:
- ATP: [ ] None [ ] ___ episodes
- Shocks: [ ] None [ ] ___ appropriate [ ] ___ inappropriate
PACING STATISTICS:
- Atrial pacing: ___%
- Ventricular pacing: ___%
- BiV pacing (if CRT): ___%
ASSESSMENT:
[ ] Normal device function, no concerning findings
[ ] Abnormal finding - action required: _______________
PLAN:
[ ] Continue remote monitoring per schedule
[ ] In-office interrogation recommended for: ___________
[ ] Programming change recommended: ___________
[ ] Patient contacted regarding: ___________
[ ] No action required
[ ] Next scheduled transmission: ___________
Reviewed by: _______________ Date: _______________
For complete telehealth documentation guidance, see our Telehealth SOAP Notes Guide.
Specialty Documentation Templates
Murmur Documentation Template
Cardiac Murmur Documentation
CARDIAC MURMUR DOCUMENTATION
MURMUR CHARACTERISTICS:
- Timing: [ ] Systolic [ ] Diastolic [ ] Continuous
- Duration: [ ] Early [ ] Mid [ ] Late [ ] Holo/Pan
- Grade: ___/6 (systolic) or ___/4 (diastolic)
- Systolic: 1=barely audible, 2=soft, 3=moderate, 4=loud+thrill, 5=very loud+thrill, 6=audible without stethoscope
- Diastolic: 1=barely audible, 2=soft, 3=moderate, 4=loud
- Quality: [ ] Blowing [ ] Harsh [ ] Rumbling [ ] Musical
- Pitch: [ ] High [ ] Medium [ ] Low
- Location (loudest): [ ] RUSB [ ] LUSB [ ] LLSB [ ] Apex [ ] Other: ___
- Radiation: [ ] Carotids [ ] Axilla [ ] Back [ ] None [ ] Other: ___
DYNAMIC MANEUVERS:
- Valsalva: [ ] Increases [ ] Decreases [ ] No change
- Standing: [ ] Increases [ ] Decreases [ ] No change
- Squatting: [ ] Increases [ ] Decreases [ ] No change
- Handgrip: [ ] Increases [ ] Decreases [ ] No change
- Inspiration: [ ] Increases [ ] Decreases [ ] No change
ASSOCIATED FINDINGS:
- S1: [ ] Normal [ ] Loud [ ] Soft [ ] Variable
- S2: [ ] Normal [ ] Wide split [ ] Fixed split [ ] Paradoxical split [ ] Single
- S3: [ ] Present [ ] Absent
- S4: [ ] Present [ ] Absent
- Ejection click: [ ] Present [ ] Absent
- Opening snap: [ ] Present [ ] Absent
SUSPECTED ETIOLOGY:
[ ] Aortic stenosis
[ ] Aortic regurgitation
[ ] Mitral regurgitation
[ ] Mitral stenosis
[ ] Tricuspid regurgitation
[ ] Mitral valve prolapse
[ ] Hypertrophic cardiomyopathy
[ ] Innocent/flow murmur
[ ] Other: _______________
COMPARISON TO PRIOR: [ ] New [ ] Unchanged [ ] Changed: ___________
PLAN: [ ] Echo ordered [ ] Prior echo available [ ] Clinical monitoring
Heart Failure Assessment Template
Heart Failure Assessment Template
HEART FAILURE COMPREHENSIVE ASSESSMENT
CLASSIFICATION:
- ACC/AHA Stage: [ ] A (at risk) [ ] B (structural, no symptoms) [ ] C (symptomatic) [ ] D (refractory)
- NYHA Functional Class: [ ] I [ ] II [ ] III [ ] IV
- Phenotype: [ ] HFrEF (EF ≤40%) [ ] HFmrEF (EF 41-49%) [ ] HFpEF (EF ≥50%)
- Etiology: [ ] Ischemic [ ] Non-ischemic [ ] Valvular [ ] Other: ___
VOLUME STATUS:
- Weight today: ___ lbs/kg
- Dry weight: ___ lbs/kg
- Weight change: ___ from baseline
CONGESTION ASSESSMENT (check if present):
[ ] Orthopnea (pillows: ___)
[ ] PND
[ ] Peripheral edema (grade: ___, location: ___)
[ ] Elevated JVP (___ cm H2O)
[ ] Hepatojugular reflux
[ ] S3 gallop
[ ] Pulmonary rales/crackles
[ ] Hepatomegaly
[ ] Ascites
[ ] Elevated BNP/NT-proBNP (___ pg/mL)
PERFUSION ASSESSMENT (check if present):
[ ] Cool extremities
[ ] Narrow pulse pressure
[ ] Hypotension (SBP <90)
[ ] Altered mental status
[ ] Worsening renal function
[ ] Low cardiac index (if measured)
CONGESTION/PERFUSION PROFILE:
[ ] Warm and Dry (compensated)
[ ] Warm and Wet (congested, adequate perfusion)
[ ] Cold and Dry (hypoperfused, not congested)
[ ] Cold and Wet (cardiogenic shock)
GUIDELINE-DIRECTED MEDICAL THERAPY (GDMT):
| Medication Class | Current | Target Dose | At Target? | Barrier |
|------------------|---------|-------------|------------|---------|
| ARNI or ACEi/ARB | | | | |
| Beta-blocker | | | | |
| MRA | | | | |
| SGLT2i | | | | |
| Loop diuretic | | PRN | N/A | |
| Hydralazine/nitrate (if indicated) | | | | |
BARRIERS TO GDMT OPTIMIZATION:
[ ] Hypotension
[ ] Bradycardia
[ ] Hyperkalemia
[ ] Renal dysfunction
[ ] Intolerance/side effects: ___
[ ] Cost/access
[ ] Patient preference
DEVICE THERAPY:
- ICD indication: [ ] Yes [ ] No [ ] Already implanted
- CRT indication: [ ] Yes [ ] No [ ] Already implanted
LABS:
- BNP/NT-proBNP:
- Creatinine:
- eGFR:
- Potassium:
- Sodium:
- Hemoglobin:
ECHOCARDIOGRAM:
- LVEF: ___%
- Wall motion abnormalities:
- Valvular disease:
- RVSP:
- RV function:
ASSESSMENT SUMMARY:
_______________________________________________
PLAN:
1. GDMT optimization:
2. Diuretic adjustment:
3. Monitoring plan:
4. Device therapy:
5. Advanced therapies consideration:
6. Follow-up:
Free Cardiology SOAP Note Template
CARDIOLOGY SOAP NOTE TEMPLATE
PATIENT: _______________ DOB: ___________ MRN: ___________
DATE: _______________ VISIT TYPE: [ ] New [ ] Follow-up
REFERRING PROVIDER: _______________
═══════════════════════════════════════
SUBJECTIVE
═══════════════════════════════════════
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
- Symptom: [ ] Chest pain [ ] Dyspnea [ ] Palpitations [ ] Syncope [ ] Edema [ ] Other: ___
- Onset:
- Duration:
- Frequency:
- Severity:
- Aggravating factors:
- Alleviating factors:
- Associated symptoms:
CHEST PAIN CHARACTERIZATION (if applicable):
- Location:
- Quality:
- Radiation:
- Provoking factors:
- Relieving factors (rest, NTG):
- [ ] Typical angina [ ] Atypical [ ] Non-cardiac
DYSPNEA (if applicable):
- NYHA Class: [ ] I [ ] II [ ] III [ ] IV
- Orthopnea: [ ] Yes (pillows: ___) [ ] No
- PND: [ ] Yes [ ] No
- Exertional tolerance:
CARDIAC RISK FACTORS:
[ ] Hypertension - duration: ___, control: ___
[ ] Diabetes - HbA1c: ___
[ ] Hyperlipidemia - LDL: ___
[ ] Tobacco use - pack-years: ___, current/former/never
[ ] Family hx premature CAD (<55M, <65F)
[ ] Obesity - BMI: ___
[ ] Sedentary lifestyle
[ ] CKD - stage: ___
PAST CARDIAC HISTORY:
[ ] CAD - intervention: ___
[ ] Heart failure - EF: ___, last echo: ___
[ ] Arrhythmia: ___
[ ] Valvular disease: ___
[ ] Prior cardiac surgery: ___
[ ] Device: [ ] Pacemaker [ ] ICD [ ] CRT
CURRENT CARDIAC MEDICATIONS:
- Antiplatelet/Anticoagulant:
- Beta-blocker:
- ACEi/ARB/ARNI:
- Statin:
- Diuretic:
- Antiarrhythmic:
- Other:
ALLERGIES:
═══════════════════════════════════════
OBJECTIVE
═══════════════════════════════════════
VITAL SIGNS:
- BP: ___/___ mmHg (sitting) ___/___ mmHg (standing if orthostatics)
- HR: ___ bpm, [ ] Regular [ ] Irregular
- RR: ___ /min
- SpO2: ___% on ___
- Weight: ___ (change from last: ___)
- BMI: ___
GENERAL:
NECK:
- JVP: ___ cm H2O
- Hepatojugular reflux: [ ] Positive [ ] Negative
- Carotid pulses: [ ] Normal [ ] Bruits [ ] Diminished
CARDIOVASCULAR:
- PMI: [ ] Normal [ ] Displaced (location: ___)
- S1: [ ] Normal [ ] Abnormal: ___
- S2: [ ] Normal [ ] Split: ___
- S3: [ ] Present [ ] Absent
- S4: [ ] Present [ ] Absent
- Murmurs: [ ] None [ ] Present: ___
- Rubs: [ ] None [ ] Present
PULMONARY:
- Breath sounds: [ ] Clear [ ] Crackles (location: ___) [ ] Wheezes
ABDOMEN:
- Hepatomegaly: [ ] Yes [ ] No
- Ascites: [ ] Yes [ ] No
EXTREMITIES:
- Edema: [ ] None [ ] Present (grade: ___, location: ___)
- Pulses: DP ___ PT ___
- Perfusion: [ ] Warm [ ] Cool
ECG:
- Rate: ___ bpm
- Rhythm:
- Axis:
- Intervals: PR ___ QRS ___ QTc ___
- ST-T changes:
- Comparison to prior:
ECHOCARDIOGRAM (if performed/available):
- LVEF: ___%
- Wall motion:
- LV size:
- RV function:
- Valvular findings:
- RVSP:
- Other:
LABORATORY:
- BNP/NT-proBNP:
- Troponin:
- BMP: Na ___ K ___ Cr ___ BUN ___
- Lipids: TC ___ LDL ___ HDL ___ TG ___
- HbA1c:
- CBC:
DEVICE INTERROGATION (if applicable):
- Battery:
- Leads:
- Arrhythmias:
- Therapies:
- Pacing %:
═══════════════════════════════════════
ASSESSMENT
═══════════════════════════════════════
1. Primary Diagnosis (ICD-10):
2. Secondary Diagnoses:
RISK STRATIFICATION:
- ASCVD 10-year risk: ___%
- CHA2DS2-VASc (if AFib): ___
- HAS-BLED (if on anticoagulation): ___
- Other scores: ___
GDMT ASSESSMENT (if HF):
| Class | Medication | Dose | Target | At Goal? |
|-------|------------|------|--------|----------|
| ARNI/ACEi/ARB | | | | |
| Beta-blocker | | | | |
| MRA | | | | |
| SGLT2i | | | | |
═══════════════════════════════════════
PLAN
═══════════════════════════════════════
1. MEDICATIONS:
- New:
- Adjusted:
- Discontinued:
- Continued:
2. DIAGNOSTICS ORDERED:
- Labs:
- Imaging:
- Other:
3. PROCEDURES PLANNED:
4. LIFESTYLE MODIFICATIONS:
- Diet:
- Exercise:
- Smoking cessation:
- Weight management:
5. CARDIAC REHABILITATION:
- [ ] Referred [ ] Not indicated [ ] Already enrolled
6. MONITORING:
- Weight:
- BP:
- Remote device monitoring:
7. CONSULTATIONS:
8. PATIENT EDUCATION PROVIDED:
9. FOLLOW-UP:
- Next appointment:
- Return precautions:
Provider: _______________ Date: _______________
Attending attestation (if applicable): _______________
Related Resources
- Emergency Medicine SOAP Notes
- Telehealth SOAP Notes Guide
- AI-Assisted Documentation Guide
- Free SOAP Note Templates
Frequently Asked Questions
Cardiology SOAP notes should document relevant risk scores based on the clinical scenario. For primary prevention, include the ASCVD 10-year risk score. For atrial fibrillation patients, document CHA2DS2-VASc score for stroke risk and HAS-BLED score for bleeding risk. For acute chest pain, the HEART score is essential. For heart failure patients, include ACC/AHA stage and NYHA functional class. These validated scores support clinical decision-making and demonstrate guideline-directed care.
Document heart failure using ACC/AHA staging (A-D) and NYHA functional classification (I-IV). Create a GDMT table showing each medication class (ARNI/ACEi/ARB, beta-blocker, MRA, SGLT2i), current dose, target dose, and whether at target. Note barriers to optimization such as hypotension, bradycardia, or renal dysfunction. Document the patient's congestion and perfusion profile (warm/cold, wet/dry) and ejection fraction with comparison to prior values.
Document murmurs systematically including: timing (systolic, diastolic, continuous), duration (early, mid, late, holo/pan), grade (1-6 for systolic, 1-4 for diastolic), quality (blowing, harsh, rumbling, musical), pitch (high, medium, low), location of maximum intensity, and radiation pattern. Include dynamic maneuver responses (Valsalva, standing, squatting, handgrip) and associated findings (S3, S4, clicks, rubs). Document your suspected etiology and comparison to prior examinations.
For ECG documentation, include: rate, rhythm, axis, intervals (PR, QRS, QTc), atrial abnormalities, ventricular hypertrophy criteria, ST-T changes, Q waves, and comparison to prior ECGs. For echocardiograms, document: LV size and ejection fraction, wall motion abnormalities, RV size and function, valvular assessment with severity grading, diastolic function parameters, RVSP, IVC size and collapsibility, and pericardial findings. Always compare to prior studies.
Telehealth cardiology notes should document: the platform used (HIPAA-compliant), patient and provider locations, consent for telehealth, and visit appropriateness. Include remote patient monitoring data (weight trends, blood pressure readings, heart rate). Document modified examination findings via video observation. Note examination limitations (unable to auscultate, perform orthostatic vitals, or physically examine). Include ICD/pacemaker remote transmission data if applicable and specify when in-person follow-up is recommended.
Document device type, manufacturer, model, and implant date. Include battery status with estimated longevity. For each lead, document threshold, impedance, and sensing values with comparison to prior. Record arrhythmia episodes (AF burden, NSVT episodes, VT/VF events), therapies delivered (ATP, shocks with appropriateness), and pacing percentages. Note any alerts or concerning findings and document your assessment and plan including programming changes and follow-up schedule.
Yes, SOAPNoteAI.com offers AI-assisted documentation specifically designed for healthcare providers including cardiologists. The platform is fully HIPAA-compliant with a signed Business Associate Agreement (BAA) and works on iPhone, iPad, and web browsers. It can capture complex cardiology encounters including symptom characterization, medication reconciliation, examination findings, and GDMT assessments. The AI helps ensure comprehensive documentation while reducing documentation burden, and it works for any medical specialty.
Medical Disclaimer: This content is for educational purposes only and should not replace professional medical judgment. Always consult current clinical guidelines and your institution's policies.