Cardiology encounters involve dense clinical data — medication lists with narrow therapeutic windows, imaging results that drive management decisions, and risk stratification that needs to be documented clearly. This template is structured for the information density that cardiology demands.
Disclaimer: This template is for documentation structure only. Practices should adapt it to their clinical, legal, and organizational requirements.
Cardiology follow-up visit template
SUBJECTIVE
Visit type: Cardiology follow-up — [Condition(s): e.g., heart failure, atrial fibrillation, CAD]
Interval history:
- Symptom status since last visit: [Improved / Stable / Worsening]
- Chest pain: [Presence, character, frequency, triggers, duration, relief]
- Dyspnea: [At rest / On exertion — specify activity level, orthopnea, PND]
- Palpitations: [Frequency, duration, associated symptoms, triggers]
- Edema: [Location, severity, changes with position or time of day]
- Syncope/presyncope: [Episodes since last visit, circumstances]
- Exercise tolerance: [Current activity level, limitations, changes from baseline]
- Weight changes: [Gain/loss, time frame — critical for heart failure]
Functional status: [NYHA class if heart failure: I / II / III / IV]
Medication review:
- Current cardiac medications: [Each with dose, frequency]
- Adherence: [Taking as prescribed? Barriers? Cost issues?]
- Side effects: [Dizziness, bradycardia, fatigue, cough, bleeding, GI — specify which medication]
- Recent medication changes: [By any provider since last visit]
Home monitoring:
- Blood pressure: [Home readings — range and frequency]
- Heart rate: [Home readings or wearable data if relevant]
- Daily weights: [For heart failure — trend, adherence to monitoring]
- Device data: [Pacemaker/ICD — any alerts, shocks, or symptoms?]
Review of systems: [Focused on cardiovascular and related systems]
Allergies: [List — especially contrast dye and medication allergies]
OBJECTIVE
Vital signs: BP ___ (R/L arm) | HR ___ (regular/irregular) | RR ___ | SpO2 ___ | Weight ___ | BMI ___
General: [Appearance, respiratory comfort, distress level]
Cardiovascular exam:
- Jugular venous pressure: [Estimated cm H₂O, or normal/elevated]
- Carotid pulses: [Upstroke, bruits]
- Heart sounds: S1 ___ S2 ___ | S3 ___ | S4 ___ | Murmurs: [Grade, location, timing, radiation]
- Point of maximal impulse: [Location, character]
- Rhythm: [Regular / Irregularly irregular / Regularly irregular]
Pulmonary: [Crackles, wheezes, diminished breath sounds, pleural effusion signs]
Extremities:
- Edema: [Location, severity (trace/1+/2+/3+/4+), pitting vs. non-pitting]
- Peripheral pulses: [Dorsalis pedis, posterior tibial — present/diminished/absent bilaterally]
- Capillary refill:
Abdomen: [Hepatomegaly, ascites, hepatojugular reflux — if heart failure]
Device check: [Pacemaker/ICD — interrogation results summary if performed today]
Recent test results:
- Labs: [BNP/NT-proBNP ___, BMP (Cr, K, Na) ___, CBC ___, INR ___, lipid panel ___, A1c ___]
- ECG: [Rate, rhythm, intervals, axis, ST/T changes, comparison to prior]
- Echocardiogram: [Date, EF ___, wall motion, valve function, chamber sizes, diastolic function]
- Stress test: [Date, protocol, result, Duke score, exercise capacity in METs]
- Cardiac catheterization: [Date, findings — if relevant and recent]
- Holter/event monitor: [Date, findings — burden, pauses, arrhythmias detected]
ASSESSMENT
Cardiovascular risk factors:
- Hypertension: [Controlled / Uncontrolled — current regimen]
- Diabetes: [A1c ___, management status]
- Dyslipidemia: [LDL ___, on statin Y/N, at goal Y/N]
- Tobacco: [Current / Former / Never — pack-years]
- Obesity: [BMI, trend]
- Family history of premature CAD: [Y/N]
- Risk score: [ASCVD 10-year ___ % | CHA₂DS₂-VASc ___ | HAS-BLED ___ — as applicable]
1. [Primary cardiac diagnosis] — [Status: stable / improved / decompensated / newly diagnosed]
- Current management: [Brief summary of regimen]
- Clinical trajectory: [Improving / stable / worsening over past ___ months]
2. [Secondary cardiac diagnosis] — [Status]
3. [Additional diagnoses] — [Status]
PLAN
1. [Diagnosis #1 — e.g., Heart failure with reduced EF]:
- Medication adjustment: [Titrate ___ to target dose / add ___ / continue current regimen]
- Monitoring: [Daily weights, fluid restriction, sodium restriction]
- Labs ordered: [BMP for K/Cr monitoring, BNP trend]
- Imaging/testing: [Repeat echo in ___ months, stress test if ___]
- Device: [ICD/CRT evaluation, pacemaker programming changes]
- Referral: [Cardiac rehab, EP, surgery, advanced HF if applicable]
2. [Diagnosis #2 — e.g., Atrial fibrillation]:
- Rate/rhythm control: [Current strategy, medication adjustments]
- Anticoagulation: [Agent, dose, monitoring plan, bleeding risk review]
- Referral: [EP consult for ablation if applicable]
3. [Diagnosis #3 — e.g., Hypertension]:
- Medication: [Adjust / continue]
- BP target: [Per current guidelines for this patient's risk profile]
Risk factor management:
- Lipids: [Statin adjustment, PCSK9 consideration, lifestyle]
- Diabetes: [Coordination with PCP/endocrinology, SGLT2i if indicated for HF]
- Smoking cessation: [Counseling, pharmacotherapy if applicable]
Patient education: [Topics discussed — medication changes, diet, activity, symptoms to report]
Follow-up: [Timing — e.g., 3 months, or sooner if ___]
New patient / consultation template additions
For initial cardiology consultations, expand the Subjective section to include:
ADDITIONAL HISTORY (Initial consultation)
Reason for referral: [Referring provider and clinical question]
Complete cardiac history:
- Prior MI: [Date, vessels, intervention]
- Prior interventions: [PCI — dates, vessels, stents | CABG — date, grafts | Valve surgery]
- Prior catheterization: [Date, findings]
- History of arrhythmias: [Type, treatment]
- History of heart failure: [Onset, etiology, lowest EF, hospitalizations]
- Implanted devices: [Type, date, manufacturer, last interrogation]
Complete medical history: [Non-cardiac conditions that affect cardiac management — CKD, COPD, diabetes, thyroid, sleep apnea]
Family cardiovascular history:
- Premature CAD: [First-degree relatives, age of onset]
- Sudden cardiac death: [Family members, age]
- Cardiomyopathy: [Type if known]
- Familial hyperlipidemia: [If suspected]
Medication reconciliation for cardiology
Cardiac medication lists are often long and have critical interactions. Structure your medication documentation to make it scannable:
Anti-ischemic / Anti-anginal: Beta-blocker (agent, dose), nitrate (agent, dose, use pattern), calcium channel blocker (agent, dose)
Heart failure regimen: ACEi/ARB/ARNI (agent, dose — at target?), beta-blocker (agent, dose — at target?), MRA (agent, dose), SGLT2i (agent, dose), diuretic (agent, dose — dry weight target)
Anticoagulation / Antiplatelet: Agent, dose, indication, monitoring plan, duration if time-limited (e.g., DAPT post-stent)
Lipid-lowering: Statin (agent, dose, intensity), ezetimibe, PCSK9i — with last LDL and goal
Rate / rhythm control: Agent, dose, monitoring (ECG, drug levels if applicable)
Antihypertensive: Agents not already listed above — doses, BP target
This grouping makes it easier to spot gaps in guideline-directed therapy and to reconcile medications across providers.
Documenting cardiovascular risk
Every cardiology follow-up should include an updated snapshot of modifiable risk factors. Include the relevant validated risk score for the clinical context — ASCVD for primary prevention, CHA₂DS₂-VASc for atrial fibrillation, HAS-BLED if on anticoagulation. Document the score, the date it was calculated, and whether management changes are indicated.
Risk factor documentation also supports quality measure reporting and can be pulled for population health management if your organization tracks these metrics.
Related resources
For the foundational format, see the general SOAP note template. Learn how Dictum supports cardiology-specific workflows with structured cardiac history and imaging review sections. Set up AI-generated SOAP notes configured for cardiovascular documentation.
Frequently asked questions
What makes a cardiology SOAP note different from a general template? Cardiology notes emphasize cardiovascular-specific history (chest pain characteristics, dyspnea classification, palpitations), a detailed cardiac physical exam, medication reconciliation for cardiac drugs with narrow therapeutic windows, imaging and test interpretation, and cardiovascular risk factor tracking.
How should I document cardiac imaging results? Summarize the key findings relevant to clinical decision-making — e.g., ejection fraction, wall motion abnormalities, valve function, stress test result and Duke score. Reference the full report by date and facility. Do not simply copy the entire report into the note.
What risk scoring should I include in a cardiology note? Document whatever validated risk tool is relevant to the clinical context — ASCVD 10-year risk score for primary prevention, CHA₂DS₂-VASc for atrial fibrillation stroke risk, HAS-BLED for bleeding risk on anticoagulation, or HEART score for acute chest pain evaluation.
How do I document anticoagulation management? Document the indication, agent, dose, monitoring plan (INR target range for warfarin, renal function for DOACs), bleeding history, and any drug interactions. Note patient education provided about signs of bleeding and medication adherence.
Can AI handle cardiology-specific documentation? Yes. Dictum can draft cardiology SOAP notes from encounters or dictation, including structured sections for cardiac history, imaging review, and medication management. The cardiologist reviews and finalizes every note.
Should I document functional capacity in every cardiology note? Documenting functional capacity (e.g., NYHA class for heart failure, exercise tolerance in METs, or simply what activities the patient can and cannot perform) is valuable for tracking disease progression and supporting clinical decisions. It is standard practice for heart failure and valvular disease follow-ups.
How do I organize notes for patients with multiple cardiac conditions? Number each condition in the Assessment and create a corresponding numbered Plan entry. Group related conditions when the management overlaps — for example, hypertension and heart failure often share medication decisions — but keep distinct conditions (e.g., atrial fibrillation anticoagulation) as separate entries.
Cardiac documentation as structured as the care you deliver. Try Dictum free — AI-drafted cardiology notes with imaging review and medication reconciliation sections built in.