Quick Way to Write Asthma SOAP Notes for Healthcare Providers

Asthma SOAP Notes

It's 6 PM on a Friday, you've seen 28 patients today, and you're staring at a dozen incomplete charts.

Three of them are asthma visits, and you're trying to remember which patient had the wheezing, which one needed the steroid burst, and which one you referred to pulmonology.

Your documentation needs to be thorough enough to justify your treatment decisions to insurance, but you're running on fumes.

Sound familiar? If you've ever found yourself in these shoes, keep on reading.

We've all been here.

Quick Tip:

SOAP Notes Doctor is our product that transforms recordings, audios, and text into industry-standard SOAP notes.

You can let it listen to your patient encounters and do the work.

You can add, edit, review, and add more context later.

Head over to soapnotes.doctor now.

Let's dive in.

SOAP Notes: The Quick Story

Back in the day, medical documentation was chaos.

One provider might write "patient has asthma - gave inhaler" while another would write a three-page narrative about every breath sound and symptom since childhood.

There was no consistency, no structure, and definitely no way for another provider to quickly understand what happened.

Then in the late 1960s, Dr. Lawrence Weed said "enough is enough" and created the Problem-Oriented Medical Record with SOAP notes at its core.

His brilliant idea was simple: give everyone the same template so any healthcare provider could read someone else's notes and actually understand what's going on.

Here's what Dr. Weed came up with:

• S (Subjective): What the patient tells you about their symptoms and concerns
• O (Objective): What you observe and measure during the examination
• A (Assessment): Your professional clinical judgment about what's happening
• P (Plan): What you're going to do about it

This format spread like wildfire because it just worked.

For asthma specifically, this structure became essential because you need to capture symptom frequency, triggers, medication adherence, and objective measures like peak flow or spirometry - all in a way that insurance companies and other providers can quickly understand.

How to Write Asthma SOAP Notes: My Recommended Approach

When I started working with pulmonologists and primary care docs, I noticed they'd spend forever trying to document asthma visits perfectly.

Then I discovered something that changed everything:

"Just capture what matters. Don't overthink it."

Document the essentials: symptom frequency, rescue inhaler use, triggers, exam findings, and peak flow. That's your foundation. Everything else is extra.

I picked this approach up from watching efficient providers work, and I built soapnotes.doctor around it.

There are technically two ways you can approach asthma SOAP notes. You can write them manually, or you can use soapnotes.doctor.

Use soapnotes.doctor

I'll choose soapnotes.doctor every single time because it's consistent, captures all the insurance requirements, and most importantly, it's way faster than typing everything out.

Here's how to streamline the whole process:

1. Head over to soapnotes.doctor to get started. Complete the onboarding process if you're new to the platform.

2. Click on the record button to either record the patient encounter or dictate your findings after the visit.

3. Wait 1-3 minutes.

4. Review and save.

One beauty of soapnotes.doctor is that the tool just gets it right. Not overly verbose, yet never misses the critical details that insurance companies look for. I think that's the sweet spot.

And if you need to make edits, you have the tailorr feature at your disposal. Edit, approve, add context, and copy straight to your EHR.

Write Manually

Maybe you're old school, or maybe you just want the mental exercise of writing it yourself. Here's how to do it efficiently.

1. S - Subjective

This is where you capture the patient's story about their asthma.

This section should document what your patient tells you about their breathing, symptoms, and how asthma is affecting their life.

Purpose: Document the patient's perspective on their asthma control and any acute concerns.

What to include:

• Current symptoms (cough, wheeze, chest tightness, shortness of breath)
• Symptom frequency (daytime and nighttime)
• Rescue inhaler use (frequency and effectiveness)
• Activity limitations
• Triggers and exposures
• Medication adherence
• Recent exacerbations or ED visits

Examples:

"Patient reports increased wheezing and chest tightness over past week, rating breathlessness at 6/10. Using albuterol inhaler 4-5 times daily, up from usual 2-3 times weekly. Waking up at night with cough twice this week. Denies fever or colored sputum. Suspects trigger was visiting friend with cats. Taking Flovent HFA 110mcg twice daily as prescribed."

"Patient states asthma has been well-controlled, no daytime symptoms, and using rescue inhaler only once in past month during exercise. Sleeping through night without cough or wheeze. Able to do all usual activities without limitation. Refilled controller medication last week and taking consistently."

2. O - Objective

This is where you document what you observe and measure.

The objective section is where you record your clinical findings, vital signs, and any testing results.

Purpose: Document measurable, observable data about the patient's respiratory status.

What to include:

• Vital signs (especially respiratory rate and oxygen saturation)
• Lung examination findings
• Peak flow or spirometry results
• Physical appearance (use of accessory muscles, ability to speak in full sentences)
• Skin findings (eczema, allergic shiners)
• Any other relevant physical exam findings

Examples:

"Vitals: RR 22, O2 sat 94% on room air, HR 98, BP 128/82. Patient sitting upright, speaking in short phrases. Mild use of accessory muscles noted. Lung exam reveals bilateral expiratory wheezes throughout all fields, prolonged expiratory phase. No stridor or rales. Peak flow 280 L/min (personal best 420 L/min, 67% of predicted). Heart regular rate and rhythm. No cyanosis."

"Vitals: RR 16, O2 sat 98% on room air, HR 72, BP 118/76. Patient comfortable, speaking in full sentences. Lungs clear to auscultation bilaterally with good air movement, no wheezes, rales, or rhonchi. No accessory muscle use. Peak flow 410 L/min (personal best 420 L/min, 98% of predicted). Cardiovascular exam normal."

3. A - Assessment

This section is your professional clinical assessment of the patient's asthma control.

Purpose: Connect the subjective complaints with objective findings and evaluate asthma severity and control level.

Key Principle: Focus on asthma control classification and what's driving current symptoms.

What to include:

• Asthma control level (well-controlled, not well-controlled, or very poorly controlled)
• Severity classification if applicable
• Likely triggers or exacerbating factors
• Response to current treatment
• Any complications or comorbidities

Examples:

"32-year-old female with moderate persistent asthma, currently not well-controlled. Acute exacerbation likely triggered by allergen exposure (cat dander). Increased rescue inhaler use and nocturnal symptoms indicate inadequate controller medication dosing or adherence issue. Peak flow at 67% of personal best indicates significant airflow obstruction. No signs of respiratory failure, appropriate for outpatient management with intensified treatment."

"45-year-old male with mild persistent asthma, currently well-controlled on low-dose ICS. Meeting control criteria with minimal symptoms, rare rescue inhaler use, no nighttime awakenings, and normal peak flow. Current medication regimen appears optimal for maintenance of control."

4. P - Plan

This final section outlines your treatment plan and follow-up strategy.

Purpose: Establish clear treatment adjustments and monitoring plan.

Length: Be specific and actionable, typically 3-5 key points.

What to include:

• Medication adjustments (controller and/or rescue)
• Patient education provided
• Trigger avoidance strategies
• Follow-up timing and monitoring plan
• When to seek emergency care

Examples:

"Initiated oral prednisone 40mg daily for 5 days for acute exacerbation. Increased Flovent HFA to 220mcg twice daily. Continue albuterol HFA 2 puffs every 4 hours as needed, can use every 2 hours if needed for symptom control. Educated on proper inhaler technique using spacer. Advised strict avoidance of cat exposure. Provided asthma action plan with clear instructions on when to increase medications or seek emergency care. Follow-up in 5-7 days to reassess symptoms and peak flow. Patient to call sooner if increased shortness of breath, inability to complete sentences, or peak flow drops below 200 L/min."

"Continue current Flovent HFA 110mcg twice daily. Continue albuterol HFA as needed for symptoms. Encouraged consistent use of controller medication even when feeling well. Reviewed trigger avoidance and importance of pre-medicating with albuterol before exercise. Patient demonstrates good understanding of asthma action plan. Routine follow-up in 6 months or sooner if symptoms worsen. Annual flu vaccine recommended."

Complete Asthma SOAP Note Examples

Now let's look at three complete examples that bring all these components together.

Example 1: Acute Asthma Exacerbation

Patient: 28-year-old female
Visit Type: Urgent care visit
Chief Complaint: Worsening asthma symptoms for 3 days

S – Subjective:

Patient presents with worsening asthma symptoms over past 3 days. Reports progressive shortness of breath, chest tightness rated 7/10, and persistent dry cough. Using albuterol inhaler every 2-3 hours with only partial relief lasting 30-45 minutes. Woke up last two nights gasping for air. Denies fever, chills, or productive cough with colored sputum. No recent sick contacts. States symptoms began after exposure to cold air during outdoor event. Has been taking Flovent HFA 110mcg twice daily as prescribed. No recent oral steroid use. Last exacerbation requiring prednisone was 8 months ago. Denies any ED visits or hospitalizations for asthma in past year. Reports difficulty climbing stairs at home due to breathlessness. Concerned because albuterol not providing usual relief.

O – Objective:

Vitals: BP 132/84, HR 104, RR 24, O2 sat 92% on room air (increases to 96% with supplemental oxygen 2L NC), Temp 98.2°F
General: Patient appears anxious, sitting upright and leaning forward, speaking in 3-4 word phrases
HEENT: No nasal flaring, no cyanosis
Neck: No stridor, mild use of accessory muscles (sternocleidomastoid)
Lungs: Diffuse bilateral expiratory wheezes throughout all lung fields, prolonged expiratory phase, decreased air movement in bases, no crackles, mild tachypnea
Cardiovascular: Tachycardic but regular rhythm, no murmurs
Peak Flow: 240 L/min (personal best 380 L/min, 63% of predicted)
After albuterol nebulizer treatment: Peak flow improved to 290 L/min (76% of predicted), RR 20, O2 sat 95% on room air, wheezing decreased but still present, patient able to speak in fuller sentences

A – Assessment:

28-year-old female with known moderate persistent asthma presenting with acute exacerbation, likely triggered by cold air exposure. Currently not well-controlled with significant airflow obstruction evidenced by peak flow at 63% of personal best and diffuse wheezing on exam. Symptoms have been progressive over 3 days with increased rescue inhaler use and nighttime awakenings, meeting criteria for acute exacerbation requiring systemic corticosteroids. Patient showed partial response to nebulized albuterol with improvement in peak flow to 76% of predicted and subjective symptom relief. No signs of respiratory failure or need for hospitalization at this time. Appropriate for outpatient management with close follow-up.

P – Plan:

Administered albuterol nebulizer treatment 2.5mg in clinic with good response. Prescribed prednisone 40mg PO daily for 5 days to treat acute exacerbation. Increased Flovent HFA from 110mcg to 220mcg two puffs twice daily for better long-term control. Continue albuterol HFA 2 puffs every 4 hours as needed, may use every 2 hours if symptoms worsen. Educated patient on proper inhaler technique with spacer demonstration - patient demonstrated correct technique. Provided written asthma action plan with yellow zone and red zone instructions. Advised avoidance of cold air exposure; recommend using scarf over mouth and nose if must go outdoors in cold weather. Patient to monitor peak flow twice daily and keep log. Strict return precautions: seek emergency care if peak flow drops below 190 L/min (50% of personal best), difficulty speaking, chest pain, confusion, or if albuterol needed more frequently than every 2 hours. Follow-up appointment scheduled in 5 days to reassess response to treatment and adjust medications as needed. Patient verbalized understanding of all instructions and warning signs.

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Example 2: Routine Asthma Follow-Up, Well-Controlled

Patient: 42-year-old male
Visit Type: Routine follow-up
Chief Complaint: Asthma medication refill and check-up

S – Subjective:

Patient presents for routine asthma follow-up. Reports excellent asthma control over past 3 months since last visit. No daytime symptoms, no nighttime awakenings due to asthma. Using albuterol rescue inhaler only 2-3 times per month, primarily before vigorous exercise. Able to participate in all activities without limitation including running 3 miles three times weekly. Denies cough, wheeze, or chest tightness. Taking Advair Diskus 250/50 one puff twice daily consistently, uses reminder on phone to maintain schedule. No missed doses in past month. No recent respiratory infections or exacerbations. Last oral steroid course was over 2 years ago. Received flu vaccine in October as recommended. Reports good understanding of asthma triggers (strong perfumes, cold air, viral infections) and avoids these when possible. No ED visits or urgent care visits for asthma since last appointment. Feels current medication regimen is working well.

O – Objective:

Vitals: BP 122/78, HR 68, RR 14, O2 sat 99% on room air, Weight 182 lbs
General: Well-appearing, no distress, conversing comfortably
Lungs: Clear to auscultation bilaterally in all fields, good air exchange, symmetric chest expansion, no wheezes, rales, or rhonchi, normal resonance to percussion
Cardiovascular: Regular rate and rhythm, no murmurs
Skin: No eczema or rash
Peak Flow: 510 L/min (personal best 520 L/min, 98% of predicted)
Spirometry: FEV1 3.8L (102% predicted), FVC 4.5L (98% predicted), FEV1/FVC ratio 0.84 (normal)

A – Assessment:

42-year-old male with mild persistent asthma, currently well-controlled on low-dose ICS/LABA combination therapy. Patient meets all criteria for well-controlled asthma: no daytime symptoms, no nighttime awakenings, minimal rescue inhaler use (less than 2 days per week), no activity limitation, and normal lung function on spirometry. Excellent medication adherence and trigger awareness. No evidence of exacerbation risk. Current therapy at appropriate step of asthma management guidelines. Patient demonstrates strong asthma self-management skills.

P – Plan:

Continue current regimen: Advair Diskus 250/50 one puff twice daily. Continue albuterol HFA 2 puffs as needed before exercise or for symptoms (currently using 2-3 times monthly, which is appropriate). Refilled both medications for 90-day supply. Reinforced importance of continuing controller medication daily even when feeling well, as this prevents exacerbations. Reviewed asthma action plan, patient demonstrates clear understanding of green, yellow, and red zones. Encouraged continuation of regular exercise as this improves overall lung function. Discussed allergen avoidance strategies for known triggers. Patient reminded to pre-medicate with albuterol 15 minutes before vigorous exercise. Given excellent control, discussed potential step-down therapy in future if control maintained for 3 more months, though current therapy is well-tolerated with no side effects. Routine follow-up in 6 months for asthma check. Patient to contact office sooner if increased symptoms, rescue inhaler use more than twice weekly, or any nighttime awakenings due to asthma. Next flu vaccine due in 9 months. Patient expressed satisfaction with current management and has no questions at this time.

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Example 3: Pediatric Asthma Visit with Poor Control

Patient: 9-year-old male
Visit Type: Follow-up, brought by mother
Chief Complaint: Frequent asthma symptoms despite medications

S – Subjective:

Mother reports patient has been having asthma symptoms 4-5 days per week over past month. Child complains of cough and chest tightness, particularly during and after soccer practice. Using albuterol inhaler 5-6 times per week, sometimes twice daily. Waking up at night with cough approximately 2 nights per week. Mother states symptoms are "definitely worse than last visit 3 months ago." Patient missed 2 days of school last month due to asthma symptoms. Able to run and play but stops to catch breath more frequently than teammates. Mother states she gives Flovent HFA 44mcg two puffs twice daily "most days" but admits sometimes forgets morning dose when rushing to school. Patient had one course of oral steroids 2 months ago for exacerbation. No recent respiratory infections. No smoke exposure at home. Family dog lives indoors. Mother unsure of proper inhaler technique and whether spacer is needed. Patient denies triggers but mother notes symptoms worse on high pollen days and after playing with dog.

O – Objective:

Vitals: BP 102/64, HR 88, RR 18, O2 sat 97% on room air, Height 52 inches, Weight 65 lbs
General: Alert, active child, no acute distress at rest
HEENT: Mild allergic shiners noted, clear rhinorrhea, no nasal polyps
Lungs: Scattered expiratory wheezes bilaterally, more prominent in upper lobes, mild prolongation of expiratory phase, good air movement, no retractions at rest
Cardiovascular: Regular rate and rhythm, no murmurs
Skin: Mild eczema on antecubital fossae
Peak Flow: 180 L/min (predicted 215 L/min for age/height, 84% of predicted)
Inhaler Technique Assessment: Patient demonstrates poor MDI technique - not shaking inhaler, inadequate breath hold, spraying into mouth without coordination. No spacer being used.

A – Assessment:

9-year-old male with moderate persistent asthma, currently not well-controlled. Patient meets criteria for poorly controlled asthma with symptoms more than 2 days per week, nighttime awakenings 2 times per week, and activity limitation. Current low-dose ICS regimen insufficient for symptom control. Contributing factors include suboptimal medication adherence (missing morning doses), poor inhaler technique without spacer device, and likely allergic triggers (allergic rhinitis symptoms, eczema, family dog). Recent oral steroid course 2 months ago indicates increased exacerbation risk. Peak flow at 84% of predicted suggests persistent airflow limitation. Step-up therapy indicated per asthma guidelines given poor control on current regimen. Allergic component to asthma suggested by associated atopic conditions and symptom pattern.

P – Plan:

Step up asthma therapy: Increase Flovent HFA from 44mcg to 110mcg (low-medium dose for pediatrics) two puffs twice daily. Provided AeroChamber Plus spacer with mask and demonstrated proper MDI technique to patient and mother. Patient practiced technique in office until proficient. Continue albuterol HFA 2 puffs every 4-6 hours as needed for symptoms; pre-medicate 15 minutes before soccer practice. Addressed medication adherence: recommended setting phone alarm for morning dose and keeping inhaler with toothbrush as reminder. Provided written asthma action plan with illustrations appropriate for child's age. Discussed environmental modifications: keep dog out of patient's bedroom, use allergen-proof mattress cover, vacuum frequently with HEPA filter. Initiated trial of fluticasone nasal spray for allergic rhinitis which may be contributing to poor asthma control. Referred to allergist for comprehensive testing and potential immunotherapy given strong allergic component. Educated mother on peak flow monitoring - provided peak flow meter with instructions to check daily and log results. School notification: will provide letter for school nurse regarding inhaler use and PE modifications. Follow-up in 2-3 weeks to assess response to increased therapy and adherence. Mother to call sooner if increased symptoms, rescue inhaler needed more than every 4 hours, or difficulty breathing. Discussed signs requiring emergency care: difficulty speaking, lips/nails turning blue, retractions, or peak flow below 108 L/min (50% of predicted). Mother verbalized understanding and expressed commitment to improving medication routine.

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Additional Tips for Asthma SOAP Notes

Use Specific Metrics: Document actual numbers - peak flow readings, rescue inhaler frequency, nighttime awakenings per week. These justify treatment decisions to insurance.

Classification Matters: Always document asthma control level (well-controlled, not well-controlled, very poorly controlled) and severity when applicable. This drives step therapy requirements.

Medication Details: Document specific medications, doses, and frequencies. Also note adherence and technique, as these are common reasons for poor control.

Trigger Identification: Document known triggers and exposures. This explains exacerbations and guides prevention strategies.

Action Plans: Note that you reviewed or provided an asthma action plan. Many insurance audits specifically look for this.

Risk Factors: Document factors that increase exacerbation risk: history of intubation, recent hospitalizations, frequent oral steroid use, poor adherence.

Follow-Up Timing: Justify your follow-up interval based on control level. Poorly controlled asthma warrants 2-4 week follow-up, while well-controlled can be 3-6 months.

Implementing structured SOAP notes in your asthma practice ensures comprehensive patient care, demonstrates appropriate step therapy, and provides clear documentation for insurance requirements and quality metrics.