Complete Guide to COPD SOAP Note Examples for Healthcare Providers

If you've ever struggled to document COPD visits in a way that justifies treatment escalation and meets insurance requirements, this guide is for you.

I've talked to countless pulmonologists, primary care physicians, and nurse practitioners who manage COPD patients and spend considerable time documenting exacerbations, medication adjustments, and functional decline.

The reality is that COPD documentation has specific requirements that insurance companies scrutinize carefully.

They want to see clear severity classification, objective measures of disease progression, appropriate medication escalation following guidelines, and evidence that advanced therapies are medically necessary.

That's exactly why I built SOAP Notes Doctor to handle the documentation burden while you focus on optimizing patient management.

In this article, I'll show you exactly how to write COPD SOAP notes that meet insurance standards, with real examples you can adapt for your practice.

🧾 What SOAP Notes Really Are (And Why They Matter for COPD Management)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose for chronic respiratory disease management.

They were introduced in the 1960s by Dr. Lawrence Weed as part of the Problem-Oriented Medical Record (POMR).

His goal was straightforward: create a documentation system that anyone reviewing a chart could understand quickly and completely.

For COPD specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of symptom severity and functional status
• Objective measures including spirometry, oxygen saturation, and exacerbation frequency
• Appropriate medication therapy following GOLD guidelines
• Medical necessity for advanced interventions like pulmonary rehabilitation, home oxygen, or biologic therapies
• Disease progression or stability over time

SOAP stands for:

• S — Subjective: What the patient reports about shortness of breath, cough, sputum production, exercise tolerance, exacerbation frequency, and medication adherence.
• O — Objective: Your clinical findings including vitals, oxygen saturation, respiratory exam, spirometry results, CAT scores, and relevant labs or imaging.
• A — Assessment: Your clinical diagnosis with GOLD classification, exacerbation risk, current disease control, and comorbidity assessment.
• P — Plan: Your treatment plan including medication adjustments, oxygen therapy, pulmonary rehabilitation, smoking cessation support, vaccinations, and follow-up timing.

This structure keeps your documentation organized, defensible, and insurance-friendly.

You're not just recording what happened—you're building a clinical narrative that justifies ongoing treatment and potential escalation of care.

How You Can Approach COPD SOAP Notes

There's no single correct method for writing COPD SOAP notes, but some approaches work better than others depending on your practice setting.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: typing out each section after each visit. It works if you have dedicated documentation time and strong clinical writing skills. The challenge is it's time-consuming, especially when managing multiple chronic disease patients daily, and notes can become repetitive or miss important trend comparisons.

2. SOAP Notes Doctor

You record your examination findings or dictate your observations, and the tool automatically structures everything into proper SOAP format. It maintains consistency, saves hours of documentation time, and ensures you capture all the elements insurance companies require for COPD management and medication approvals.

How to Make COPD SOAP Notes Faster

One of the biggest complaints I hear from providers managing COPD patients is how documentation eats into their limited time.

You've just finished a full clinic day seeing patients with complex respiratory disease, each requiring careful assessment of symptoms, review of inhaler technique, and medication adjustments, and instead of catching up on results or going home, you're stuck typing detailed notes.

The pressure is real: make them too brief and you risk denials for expensive medications or pulmonary rehabilitation; make them too detailed and you've just added hours to your workweek.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your examination findings or dictate key observations
✅ Generate properly formatted SOAP notes instantly
✅ Get your documentation done efficiently

With soapnotes.doctor, you can record during or right after a visit, add rough notes about specific findings, or even upload audio later. The system converts everything into insurance-compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness that insurance companies require for medication approvals, but without manually typing every detail.

Maybe you noted specific findings?

"Wheezing bilaterally, SpO2 91% on room air, using rescue inhaler 3-4 times daily, two exacerbations requiring prednisone in past year, CAT score 24, FEV1 48% predicted."

Use the tailorr feature to add them. Keep it raw and unpolished—soapnotes.doctor handles the rest.

Example 1: COPD Exacerbation, Outpatient Management

Patient: 64-year-old male with moderate COPD
Chief Complaint: Worsening shortness of breath and cough for 3 days
Visit: Urgent sick visit

S – Subjective:

Patient reports acute worsening of dyspnea over past 3 days. Baseline dyspnea is with walking one block, now short of breath with minimal activity like dressing. Increased cough frequency with change in sputum from clear to yellow-green, producing approximately 2 tablespoons daily. Using albuterol rescue inhaler every 2-3 hours with minimal relief (baseline usage 1-2 times weekly). Denies fever, chills, or chest pain. No hemoptysis. Reports decreased appetite and energy. Sleeping semi-upright in recliner past 2 nights. Completed last course of antibiotics/steroids 4 months ago for previous exacerbation. Taking maintenance medications as prescribed: tiotropium daily, fluticasone/salmeterol twice daily. Former smoker, quit 3 years ago (40 pack-year history). Denies recent sick contacts or travel.

O – Objective:

Vital Signs: BP 138/84, HR 96, RR 24, Temp 98.8°F, SpO2 88% on room air (baseline 92-93%)
General: Mild respiratory distress, speaking in short phrases
HEENT: No cyanosis
Pulmonary: Decreased breath sounds bilaterally, diffuse expiratory wheezes, prolonged expiratory phase, using accessory muscles, no crackles
Cardiac: Tachycardic, regular rhythm, no murmurs
Extremities: No cyanosis or edema
Spirometry (from 6 months ago): FEV1 52% predicted, FEV1/FVC 0.58, post-bronchodilator FEV1 improvement 8%
CXR (portable): Hyperinflation, flattened diaphragms, no infiltrate or pneumothorax

A – Assessment:

Acute exacerbation of COPD, moderate severity. Clinical presentation consistent with infectious exacerbation given purulent sputum and symptom progression. GOLD Grade 2 (moderate airflow limitation), Group B (increased symptoms, low exacerbation risk transitioning to higher risk with this second exacerbation in 12 months). Hypoxemia present. No evidence of pneumonia on exam or imaging. Patient appropriate for outpatient management given stable vital signs and adequate oral intake.

P – Plan:

Acute Exacerbation Management: Prescribed prednisone 40mg daily for 5 days. Prescribed azithromycin 500mg day 1, then 250mg daily for 4 days to cover typical respiratory pathogens. Increased albuterol to 2 puffs every 4 hours scheduled while symptomatic. Continue tiotropium and fluticasone/salmeterol at current doses.

Oxygen Support: Patient's home oximeter shows SpO2 88%, which is below goal. Provided prescription for supplemental oxygen 2L nasal cannula to maintain SpO2 greater than 90%, to be used continuously until follow-up. Arranged home oxygen delivery.

Monitoring: Patient to monitor symptoms daily. Return to clinic or go to ED if worsening dyspnea, confusion, inability to eat/drink, or SpO2 drops below 88% despite oxygen. Provided written action plan.

Follow-up: Telephone check-in 48 hours to assess response to treatment. Office visit in 2 weeks for reassessment and medication optimization discussion given second exacerbation. Patient verbalized understanding of warning signs and treatment plan.

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Example 2: Stable COPD, Medication Optimization

Patient: 58-year-old female with severe COPD
Chief Complaint: Follow-up for COPD management
Visit: Routine pulmonology follow-up

S – Subjective:

Patient reports relatively stable symptoms since last visit 3 months ago. Dyspnea with walking half a block on level ground or one flight of stairs. Able to perform most activities of daily living with rest breaks. Morning cough productive of small amount of clear to white sputum. Using albuterol rescue inhaler 2-3 times daily. No recent exacerbations. Compliant with tiotropium/olodaterol daily and fluticasone/vilanterol daily. Completed pulmonary rehabilitation 6 months ago, continues home exercise program 3 times weekly. Former smoker, quit 5 years ago. Received flu vaccine 2 weeks ago. Denies weight loss, night sweats, or hemoptysis.

O – Objective:

Vital Signs: BP 128/76, HR 82, RR 18, SpO2 93% on room air, BMI 22.3
General: Well-appearing, comfortable at rest, no accessory muscle use
Pulmonary: Decreased breath sounds throughout, mild expiratory wheezes, no crackles
Cardiac: Regular rate and rhythm
Extremities: No clubbing, cyanosis, or edema
CAT Score: 18 (indicates medium impact on life quality)
Spirometry (performed today): FEV1 38% predicted, FEV1/FVC 0.54, no significant bronchodilator response
6-Minute Walk Test: 320 meters, SpO2 nadir 89%

A – Assessment:

Severe COPD (GOLD Grade 3) with persistent symptoms despite dual bronchodilator and ICS therapy. GOLD Group E (high symptom burden, exacerbation risk based on severity). CAT score indicates significant impact on quality of life. Desaturation with exertion noted on 6MWT. Patient appropriate candidate for triple therapy and oxygen assessment given spirometry and exercise testing.

P – Plan:

Medication Optimization: Transitioning to single-inhaler triple therapy for improved adherence and symptom control. Prescribed fluticasone/umeclidinium/vilanterol (Trelegy) one inhalation daily. Discontinue separate tiotropium/olodaterol and fluticasone/vilanterol. Continue albuterol as rescue. Reviewed proper inhaler technique with demonstration.

Oxygen Therapy: Given desaturation on 6MWT, ordered home overnight oximetry study to assess need for supplemental oxygen, particularly during sleep and activity.

Preventive Care: Patient up to date on flu vaccine. Recommended Pneumovax 23 (received 5 years ago, due for revaccination). Discussed COVID-19 booster availability.

Monitoring: Follow-up in 3 months to assess response to triple therapy with repeat CAT score. Recheck spirometry in 6 months. If symptoms not improved, will discuss biologic therapy options or enrollment in clinical trials. Patient to continue home exercise program and maintain physical activity as tolerated.

Action Plan: Reviewed COPD action plan for managing worsening symptoms. Patient has prednisone and azithromycin at home to start if experiencing exacerbation symptoms per action plan protocol. Patient verbalized understanding.

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Example 3: Advanced COPD, Home Oxygen Evaluation

Patient: 71-year-old male with very severe COPD
Chief Complaint: "Can't catch my breath even at rest"
Visit: Pulmonology consultation for oxygen therapy

S – Subjective:

Patient referred by PCP for worsening dyspnea and oxygen evaluation. Reports progressive shortness of breath over past 6 months, now dyspneic at rest and with minimal activity like walking to bathroom. Requires assistance with bathing and dressing. Sleeps in recliner, unable to lie flat. Chronic productive cough with clear to white sputum. Three exacerbations in past year requiring ED visits and oral steroids, one requiring hospitalization. Using albuterol every 2-3 hours. Compliant with triple inhaler therapy. Quit smoking 2 years ago after 60 pack-year history. Significant functional decline limiting quality of life. Difficulty maintaining weight, reports 12-pound loss over 6 months. Feels exhausted constantly.

O – Objective:

Vital Signs: BP 142/88, HR 98, RR 26, SpO2 84% on room air (improves to 92% on 3L nasal cannula), Weight 142 lbs, BMI 19.8
General: Thin, cachectic appearance, moderate respiratory distress at rest, pursed-lip breathing
Pulmonary: Severely decreased breath sounds, diffuse wheezes, hyperresonant to percussion, using accessory muscles
Cardiac: Tachycardic, distant heart sounds, loud P2 suggesting pulmonary hypertension
Extremities: Trace peripheral edema, no cyanosis
Labs: Hemoglobin 16.2 g/dL (mild polycythemia), CO2 32 mmHg (chronic retention)
Spirometry (3 months ago): FEV1 28% predicted, FEV1/FVC 0.48
ABG (on room air): pH 7.38, PaCO2 52, PaO2 54, HCO3 30, SaO2 86%
CXR: Severe hyperinflation, flattened diaphragms, enlarged pulmonary arteries

A – Assessment:

Very severe COPD (GOLD Grade 4) with chronic hypoxemic respiratory failure meeting criteria for long-term oxygen therapy. Resting hypoxemia documented with PaO2 less than 55 mmHg on room air. Evidence of chronic CO2 retention with metabolic compensation. Likely cor pulmonale given clinical signs. Severe functional impairment with significant impact on activities of daily living. High exacerbation frequency. Nutritional depletion concerning. Patient meets Medicare criteria for home oxygen therapy.

P – Plan:

Long-Term Oxygen Therapy: Patient meets criteria for continuous home oxygen (PaO2 less than 55 mmHg). Prescribed oxygen concentrator with portable system, 3L nasal cannula continuous to maintain SpO2 greater than 90%. Explained benefits of oxygen including improved survival, reduced hospitalizations, and better quality of life. Emphasized importance of continuous use (at least 15 hours daily, ideally 24 hours).

Medication Management: Continue current triple therapy. Added roflumilast 500mcg daily (PDE4 inhibitor) given FEV1 less than 50% and chronic bronchitis with frequent exacerbations. Continue albuterol for rescue.

Advanced Care Planning: Given disease severity, discussed prognosis and goals of care. Patient wishes to continue aggressive management. Will revisit advance directive discussion at future visits.

Nutritional Support: Referred to dietitian for nutritional assessment and high-calorie supplementation recommendations given significant weight loss and low BMI.

Palliative Care: Referred to palliative care for symptom management, anxiety related to dyspnea, and additional support services.

Monitoring: Close follow-up in 4 weeks to assess adaptation to oxygen therapy and symptom improvement. Consider pulmonary rehabilitation enrollment once oxygen optimized, if patient able to participate. Patient and family verbalized understanding of oxygen safety (no smoking, open flames) and proper use.

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Key Components Insurance Companies Look For in COPD SOAP Notes

When reviewing your COPD documentation, insurance companies specifically want to see:

1. GOLD Classification

Document airflow limitation severity (Grade 1-4 based on FEV1) and symptom/exacerbation group (A-E). This drives treatment decisions and medication approvals.

2. Objective Pulmonary Function Testing

Include spirometry results with FEV1 % predicted, FEV1/FVC ratio, and bronchodilator response. This is essential for diagnosis confirmation and severity classification.

3. Exacerbation History

Document frequency, severity, and treatment of exacerbations in past 12 months. This justifies medication escalation and specialist referrals.

4. Symptom Assessment Tools

CAT (COPD Assessment Test) or mMRC dyspnea scale scores demonstrate symptom burden and track response to therapy.

5. Oxygen Saturation and ABG Results

Critical for justifying home oxygen therapy. Document room air SpO2 and arterial blood gas values when applicable.

6. Medication Appropriateness

Show that treatment follows stepwise approach per GOLD guidelines. Justify triple therapy, biologics, or other expensive medications with documented inadequate response to previous therapy.

7. Smoking Status and Cessation Efforts

Always document current smoking status and cessation counseling provided.

Common Mistakes to Avoid

Missing GOLD Classification: Every COPD note should include current GOLD grade and group based on spirometry and clinical assessment.

Vague Dyspnea Documentation: Instead of "short of breath," document functional capacity: "dyspnea walking 100 feet on level ground" or use mMRC scale.

No Spirometry Documentation: If patient hasn't had recent spirometry, note when last performed and plan for repeat testing.

Inadequate Exacerbation Tracking: Document number, dates, and treatment of exacerbations in past year—this drives risk classification.

Missing CAT Scores: These validated tools demonstrate symptom burden and are often required for medication approvals.

Forgetting Smoking Cessation Counseling: Document this at every visit for current smokers—it's a quality measure and billing requirement.

No Oxygen Justification: When prescribing oxygen, document objective measurements (SpO2, ABG) that meet Medicare/insurance criteria.

Final Thoughts

COPD SOAP notes don't need to be overwhelming.

They need to be thorough and follow guidelines, yes, but they don't need to consume your life.

The key is having a system that captures essential information—spirometry, symptom scores, exacerbation history, functional status—without making you feel buried in paperwork.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that supports your clinical decisions and satisfies insurance requirements.

Your time is better spent optimizing inhaler therapy, counseling patients on disease management, and preventing hospitalizations than fighting with documentation.

That's exactly why we built this tool.

Try it out, see how much time you get back, and let me know what you think.

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