Cardiology Note: Structure and Sections
Cardiology encounter note (ischemic, heart failure, arrhythmia). Notermed's built-in Cardiology Note produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record. In the app the format is listed as Cardiologist Notes.
What the Cardiology Note contains
14 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Chief Complaint (CC)
- A short reason for the visit
- For example chest pain, palpitations, heart failure follow-up
- Or pre-op cardiac clearance
- 2
History of Present Illness (HPI)
- Reason for referral or follow-up
- Chest pain: exertional or at rest, radiation, associated symptoms
- Dyspnea and NYHA class
- Orthopnea, paroxysmal nocturnal dyspnea, edema
- Palpitations, presyncope, syncope, claudication
- Interval hospitalizations and procedures
- Adherence and symptom control
- Study results the clinician reviewed aloud
- 3
Past Medical History (PMHx)
- MI, PCI or stents, CABG
- Atrial fibrillation, heart failure
- Hypertension and hyperlipidemia
- 4
Past Surgical History (PSHx)
- Prior surgery, where provided
- 5
Family History (FHx)
- Premature CAD, sudden cardiac death, cardiomyopathy
- 6
Social History
- Smoking status, with pack-years when given
- Alcohol and drug use
- Activity level
- 7
Review of Systems (ROS)
- Only the systems raised, with the findings actually stated
- 8
Medications
- Antiplatelets, anticoagulants, statins
- Beta-blockers, ACE, ARB or ARNI
- Diuretics and antiarrhythmics
- 9
Allergies
- Allergies as stated
- No known allergies only when someone said so
- 10
Vitals
- BP, with arm and position when given
- HR and whether the rhythm is regular
- RR, SpO2
- Height, weight, BMI, weight trend
- 11
Physical Exam
- GEN, NECK and JVP
- CV: rate and rhythm, heart sounds, murmurs and gallops
- RESP, ABD
- EXT: edema, pulses, perfusion
- Only findings actually stated or dictated
- 12
Results / Diagnostics
- ECG: rate, rhythm, intervals, ischemic changes
- Echocardiogram: LVEF, chamber sizes, valves, wall motion
- Stress test
- Cardiac catheterization: vessel findings and interventions
- Holter or event monitor
- Labs: troponin, BNP or NT-proBNP, lipids, INR, electrolytes, renal function
- The report impression preserved as written
- 13
Assessment
- A problem list of the diagnoses the clinician stated
- ICD-10 codes flagged for billing verification
- Severity or class, only where the clinician stated it
- 14
Plan
- Grouped by problem, numbered
- Ischemic: antianginal, antiplatelet, statin changes
- Ischemic: stress test or catheterization, revascularization referral
- Heart failure: beta-blocker, ACE, ARB, ARNI, MRA, SGLT2i, diuretic
- Heart failure: daily weights, sodium and fluid counseling, echo interval
- Arrhythmia: rate or rhythm control, anticoagulation decision
- Arrhythmia: CHA2DS2-VASc when stated, monitor, EP referral or ablation
- Risk factors: blood-pressure and lipid targets, lifestyle counseling
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
Questions about the Cardiology Note
What sections does the cardiology note contain?
Fourteen, from Chief Complaint and History of Present Illness through the medical, surgical, family and social histories, Review of Systems, Medications, Allergies, Vitals, Physical Exam and Results and Diagnostics, to the Assessment and Plan.
Does the note record an NYHA class?
Where the clinician states one. The history records dyspnea with the NYHA class, orthopnea, paroxysmal nocturnal dyspnea and edema, palpitations, presyncope, syncope and claudication, plus interval hospitalizations and procedures.
What is reported from an echocardiogram?
LVEF, chamber sizes, valves and wall motion, with the report impression preserved as written. ECG rate, rhythm, intervals and ischemic changes, stress testing, catheterization findings, a Holter or event monitor, and labs such as troponin, BNP or NT-proBNP are reported the same way.
Is a CHA2DS2-VASc score included?
Only where it was stated. The arrhythmia part of the plan records rate or rhythm control, the anticoagulation decision, CHA2DS2-VASc when stated, monitoring, and an EP referral or ablation.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the Cardiology Note on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.