SOAP note example: chest pain
Chest pain is the presentation where the note most needs to show reasoning. Most outpatient chest pain is not cardiac, but the note must show which serious causes were considered, what was examined and measured, and what the patient was told to do if things change. The invented examples below illustrate structure only and are not clinical guidance.
Example: chest wall pain in clinic
S: 44-year-old man, 3 days of left-sided chest pain after moving furniture. Sharp, worse with twisting, deep breaths and pressing on the chest. Not related to exertion; walked up two flights of stairs without symptoms today. No radiation to arm, jaw or back. No breathlessness, palpitations, sweating, syncope, cough or fever. No leg swelling, recent travel, surgery or immobility. No previous heart disease. Non-smoker. BP normal at last check. No diabetes. Father well at 72. Paracetamol helps. O: Comfortable at rest. Temp 36.6, pulse 72 regular, BP 128/80 both arms similar, RR 14, SpO2 99% on air. Heart sounds normal, no murmur or rub. Chest clear, equal air entry. Reproducible tenderness over left 3rd and 4th costochondral junctions, reproducing his pain. Calves soft, not tender. ECG: sinus rhythm 70, normal axis, no ST or T wave changes. A: Musculoskeletal chest wall pain, likely costochondral strain. Cardiac cause considered and judged low probability: atypical features, no risk factors, normal ECG. Pulmonary embolism considered: no risk factors, normal observations. No features of pneumothorax, pericarditis or aortic dissection. P: 1. Paracetamol, avoid heavy lifting for 1 to 2 weeks. 2. Explained the working diagnosis and its limits. 3. Call emergency services for chest pain at rest lasting more than 15 minutes, pain with breathlessness, sweating or fainting, or pain spreading to the arm or jaw. 4. Review in 2 weeks if not settling, sooner if pain changes character.
What a chest pain SOAP note should contain
Subjective needs the full characterization: onset, site, character, radiation, relation to exertion, breathing, position and movement, duration, what relieves it, associated breathlessness, sweating, nausea, palpitations or syncope. Then risk factors for coronary disease (smoking, blood pressure, diabetes, lipids, family history of early heart disease) and for venous thromboembolism (immobility, surgery, travel, cancer, hormones, previous clot). Each negative you asked should be written.
Objective starts with how the patient looks and a full set of observations, with blood pressure in both arms if dissection is on the list. Then heart, lungs, chest wall, calves, and the ECG described in words, not just "normal". Troponin or other tests if taken.
The Assessment gives the working diagnosis and, more importantly, the serious causes considered with the reason each was judged likely or unlikely. A risk score used, with its components and total, belongs here. The Plan gives treatment, further tests or referral with urgency, and clear, specific emergency instructions.
Example: exertional chest pain
S: 61-year-old woman, 4 weeks of central chest tightness walking uphill, settles within 5 minutes of rest. Never at rest. Smoker, treated hypertension. No pain today. O: Pulse 76, BP 146/88, SpO2 98%. Heart and chest normal. ECG: sinus rhythm, no acute changes. A: Stable exertional chest pain, suspected angina. No features of acute coronary syndrome today. P: Urgent referral to a chest pain assessment service. Bloods: full blood count, lipids, HbA1c, kidney function. Emergency services for pain at rest, lasting over 15 minutes or with breathlessness or sweating. Smoking cessation support.
Gaps that matter in chest pain notes
- Exertional relationship not documented either way.
- Cardiovascular and thromboembolic risk factors not listed.
- ECG written as "normal" without rate, rhythm or ST comment.
- Only the final diagnosis given, with no alternatives considered.
- Emergency advice given verbally but not written.
- No time frame for the referral when one is made.
ICD-10 codes for chest pain
| Code | Meaning |
|---|---|
| R07.9 | Chest pain, unspecified (ICD-10-CM; base ICD-10 uses R07.4) |
| R07.89 | Other chest pain (ICD-10-CM) |
| R07.1 | Chest pain on breathing |
| M94.0 | Chondrocostal junction syndrome (Tietze), sometimes used for costochondritis |
| I20 (category) | Angina pectoris, once the diagnosis is made |
Symptom codes suit a visit where the cause is not confirmed; switch to the diagnosis code once it is.
ClearPass and the chest pain note
In a chest pain visit the key information is the list of questions asked and answered. With the patient's agreement, Transcribe keeps that exchange, and ClearPass writes a SOAP draft with each negative in S and the ECG and observations in O. Use Detailed mode here so the reasoning and every negative are kept.
ClearPass does not assess cardiac risk or choose the pathway; it writes what you said. The numbers check marks any rate, pressure or score in the note that did not come from the transcript. ICD-10 codes, patient instructions with the emergency advice, and a cardiology referral letter are one click each. Read the draft closely before it is used.
What ClearPass does not do
- It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
- It is not a medical device and does not make clinical decisions. It is a documentation aid.
- It does not connect to your EMR. The note is copy-ready text that pastes into any system.
Privacy
Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.
Questions
What should the Assessment of a chest pain SOAP note include?
The working diagnosis and the serious alternatives considered, each with the reason it was judged likely or unlikely, plus any risk score used with its total.
How should the ECG be documented?
Rate, rhythm, axis and a comment on ST segments and T waves, rather than 'normal ECG' alone.
Is a normal ECG enough to document that pain is not cardiac?
No single test excludes a cardiac cause. The note should show the history, risk factors, exam and tests together, with your reasoning. The example here is illustrative, not clinical guidance.
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