Today, we're zooming in on a specific yet vital part of healthcare: the chest pain SOAP note.
If you've ever wondered how clinicians efficiently document those potentially life-changing patient encounters, especially when chest pain is a concern, you're about to find out.
This blog is your ultimate guide to understanding and mastering the art of the chest pain SOAP note.
We're going to cover:
Let's dive right in!
A SOAP note is a structured way of documenting a patient encounter. It stands for Subjective, Objective, Assessment, and Plan.
You take SOAP notes to have a systematic way of organizing information about your patient.
SOAP notes provide a structured format for organizing information about your patient so you can provide the best care.
Plus, they also serve as a medical-legal document about what was done during the visit.
When a patient complains of chest pain, it's absolutely essential to get the details documented properly in a SOAP note.
As we said, the S stands for Subjective information directly from the patient.
Ask open-ended questions about the pain like:
Record the patient's answers word-for-word.
For Objective data, note vital signs and the results of a cardiac exam. Listen for abnormal heart sounds and check for swelling in the legs. Then, review any test results or scans that have already been done.
In your Assessment, you have to determine if the chest pain is likely cardiac or non-cardiac in origin based on the information gathered. For cardiac chest pain, it could be acute coronary syndrome like angina or heart attack. You'll want to rule these in or out.
Finally, the Plan details what should happen next. This may include admitting the patient into an ICU, ordering further tests like an EKG, cardiac enzymes or stress test, or scheduling a cardiology consult. You should also include any medications given.
When documenting a SOAP note, be thorough but concise. You’ll want to focus on clinically relevant details and avoid repetition. Type or dictate notes into the patient's electronic health record as soon as possible while the information is still fresh in your mind.
Need some real-world examples to get started? Here are two chest pain SOAP note examples to get you on the right track.
Subjective: 76-year-old male with a history of diabetes, hypertension, and sleep apnea presents with chest pain that began yesterday.
He describes the pain as sharp, followed by a dull ache. He has a known right bundle branch block and occasional premature ventricular contractions.
Objective: Vital signs are normal. Physical exam shows no abnormalities. EKG shows normal sinus rhythm with a right bundle branch block, similar to previous EKGs. Labs show an elevated glucose of 180 mg/dL but are otherwise normal.
Assessment: New onset chest pain in a patient with known coronary artery disease risk factors.
The pain could represent stable angina, but acute coronary syndrome cannot be ruled out based on the information available.
Plan: The patient was admitted to the hospital for further evaluation and management. Cardiac enzymes were trended, and stress testing was planned to evaluate for inducible ischemia. The patient was placed on aspirin, beta blocker, statin, and nitroglycerin as needed for chest pain.
Subjective: 67-year-old female with a history of hyperlipidemia presents with intermittent chest pain over the past week. The pain is dull, pressure-like, and lasts for 30-60 minutes.
It’s occasionally associated with nausea but no other symptoms. She denies any previous episodes of similar chest pain. Her only medication is atorvastatin.
Objective: Vital signs and physical exams are normal. EKG shows normal sinus rhythm without ischemic changes.
Assessment: The patient's presentation is concerning for angina pectoris due to underlying coronary artery disease. However, other causes of chest pain such as gastroesophageal reflux disease or chest wall pain cannot be excluded based on the information provided.
Plan: The patient was referred for an exercise stress test to evaluate for inducible ischemia. She was counseled to go to the emergency room immediately if her pain became more frequent or severe, radiated, or was associated with other symptoms.
She was also provided education on risk factor modification. Follow-up with her primary care physician was recommended after the stress test results were available.
We’re going to tell you something you probably know already: Crafting detailed notes for each patient will take up a significant portion of your time.
This is where AI tools like Lindy can take a load off your back.
Here are some ways you can use Lindy for great chest pain documentation:
Subjective (S):
Objective (O):
Assessment (A):
Plan (P):
While technology has significantly improved many healthcare areas, documenting patient interactions is still as analog as ever.
AI tools like Lindy are changing that by enhancing and optimizing these time-consuming but important jobs.
Yes, it’s best practice to take SOAP notes for each patient encounter. They provide a consistent way to document the details of a patient's condition and the care provided. SOAP notes allow you and other healthcare providers to get a quick overview of the patient's history and plan the best course of treatment.
You should review and update SOAP notes for each patient at every visit. Add details about the current visit, update the assessment and plan sections based on the latest information. It’s also a good idea to review notes from past visits to identify any changes or trends in the patient's condition over time.
The subjective section should document the patient's symptoms, medical history, and any concerns or issues from their perspective. Be sure to include details about:
There’s no single required format for SOAP notes, but most organizations have their own guidelines. The most important thing is that the notes are clear, concise, and contain all the necessary information about the patient's condition and care. A logical flow like: Subjective → Objective → Assessment → Plan works well. Within each section, be consistent in how you organize details and the level of detail you provide.
We've covered a lot of ground here! From understanding what SOAP notes are and why they matter, to walking through examples and tips, you're now equipped to start taking effective SOAP notes in your clinical practice.
As we wrap up, remember that while SOAP notes do take time, they provide essential documentation and help you get all-important details during patient visits.
So, get them right!
