SOAP note example: hypertension

Hypertension visits are short but full of numbers: clinic readings, home averages, kidney function, potassium and cardiovascular risk all have to land in the right section. Below is an invented note for a new diagnosis, a shorter review note, and a guide to what each part should contain. ClearPass drafts this kind of note from the visit itself.

Example: new diagnosis of hypertension

S: 52-year-old man seen after a workplace screening reading of 156/98. Home readings over 7 days (validated upper-arm cuff, morning and evening) average 148/94. No headache, visual change, chest pain, breathlessness or palpitations. No known kidney disease or diabetes. Smokes 5 cigarettes a day. Alcohol about 14 units a week. Father had a stroke at 64. No regular medicines; no NSAID, decongestant or liquorice use. No loud snoring or daytime sleepiness reported.
O: BP 154/96 right arm, 152/94 left arm; repeat after 5 minutes seated 150/95. Pulse 78, regular. BMI 29.4, waist 101 cm. Heart sounds normal, no murmur. No carotid or renal bruit. Peripheral pulses present, no edema. Fundi: no hemorrhages or papilledema on direct ophthalmoscopy. ECG: sinus rhythm, no voltage criteria for left ventricular hypertrophy. Urine dipstick: no blood, no protein.
A: Primary hypertension, confirmed on home average. No target-organ damage on exam or ECG; bloods pending. Added risk from smoking, family history and weight.
P: 1. Creatinine and eGFR, electrolytes, fasting lipids, HbA1c; urine albumin-to-creatinine ratio.
2. Start amlodipine 5 mg once daily; ankle swelling explained as a possible side effect.
3. Smoking cessation support offered and accepted. Salt and alcohol reduction, 150 minutes of activity a week.
4. Home readings twice daily for 7 days before review.
5. Review in 4 weeks with results; calculate 10-year cardiovascular risk when lipids return.
6. Same-day care for severe headache, chest pain, breathlessness or visual disturbance.

What each section holds in a hypertension note

• Subjective. How the diagnosis was reached (clinic, home or ambulatory average, over how many days), symptoms that hint at target-organ damage, clues to a secondary cause (onset under 40, low potassium, snoring, episodic sweating and palpitations), medicines that raise pressure (NSAIDs, decongestants, combined hormonal contraception, steroids), smoking, alcohol, salt, activity and family history. At review: adherence and side effects.
• Objective. At least two readings with arm, posture and cuff size; both arms at the first visit. Pulse rate and rhythm, BMI and waist, heart sounds, bruits, edema, fundi where examined. ECG and urine dipstick results.
• Assessment. The diagnosis, whether it is controlled against the stated target, target-organ damage found or excluded, and overall cardiovascular risk when it can be calculated.
• Plan. Tests ordered, each drug with dose and frequency, lifestyle advice actually given, the home monitoring schedule, the target, the review interval and when to seek urgent care.

The single most useful line in a hypertension note is the average that drove the decision, with where it came from. A reader six months later should be able to see why a drug was started or changed without guessing.

Example: four-week review

S: Review 4 weeks after starting amlodipine 5 mg. Home average this week 136/86. Mild ankle swelling in the evenings, not troublesome. Down to 2 cigarettes a day.
O: BP 138/88, pulse 74. Trace pitting ankle edema both sides. eGFR 88, potassium 4.3, total cholesterol 5.9 mmol/L, HbA1c 38 mmol/mol, urine albumin-to-creatinine ratio normal.
A: Hypertension improving, not yet at home target below 135/85. No kidney involvement on bloods and urine.
P: Continue amlodipine 5 mg. Second agent discussed if still above target next time. 10-year risk calculated and statin discussed; patient prefers to decide after lifestyle changes. Review in 6 weeks with a new week of home readings.

Common gaps in hypertension notes

• A clinic reading with no method: one reading, unknown arm, unknown cuff.
• Home values mentioned but no average and no number of days.
• "Continue meds" instead of each drug, dose and frequency.
• No statement of the target the patient is being treated to.
• Side effects and adherence not asked, so a poor response looks like drug failure.

ICD-10 codes for hypertension visits

The more specific codes above are from ICD-10-CM; if your system uses the base ICD-10 list, the category (I10, I11, I12, I15) is what you pick. See ICD-10 coding basics.

How ClearPass writes a hypertension note

Tap Transcribe, confirm the patient has agreed, and see the patient as usual. When you stop, ClearPass writes the visit in the SOAP structure: home averages and symptoms in S, your readings and results in O, the diagnosis and control status in A, and each drug, dose and review interval in P. Concise keeps the key points; Detailed keeps every clinical fact that was said.

Blood pressure notes are exactly where a wrong digit matters, so the numbers check marks any number in the note that was never said in the transcript. ICD-10 codes are one click away, and so are patient instructions on home monitoring or a referral letter. The note is an AI draft: read it, correct it, then paste it into your EMR.

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

Related

• SOAP note template
• SOAP note examples you can learn from
• How to write a SOAP note that colleagues can use
• An AI medical scribe for cardiology clinics
• Follow-up visit note template