Hypertension Template – SOAP note



Hypertension Subjective / HPI

Hypertension Presentation

When a patient presents for a hypertension follow-up visit you want to know what medications the patient is taking. Your dot phrase or smart phrase should include a list of the medications you usually prescribe. Then you want to know if the patient has been compliant with the treatment. Followed by the report of any side effects that could indicate low blood pressure like dizziness or symptoms that could indicate high blood pressure like a headache.

Another good thing to always review with the patient is lifestyle changes that can improve her hypertension, like exercise and healthy diet.

Hypertension Objective / Physical Exam

Hypertension Exam (PE)

Obviously, one of the main things you want to know at a hypertension follow-up visit is the patient’s vital signs. However, since the patient might have White Coat syndrome, it might be more valuable to have access to their home blood pressure readings.

Keep in mind the new hypertension guidelines from the International Society of Hypertension. The threshold for diagnosis of hypertension in the office is 140/90. While 135/85 at home.

After starting medications, the target blood pressure for patients younger than 65 years should be 140/90 for the first three months, followed by 130/80.

Do you need really need to do a physical exam? Only when pertinent.

Hypertension Assessment and Plan

Hypertension Plan

For accurate clinical documentation, always specify if the condition is controlled or uncontrolled. Outline your plan. Whether it is to continue the same medications, change them, or work on lifestyle interventions.

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