Quick Way to Write Cough SOAP Notes for Healthcare Providers

Cough SOAP Notes

It's Monday morning in urgent care, and you've already seen five patients with cough before 10 AM.

One has a dry cough for 3 days, another has been coughing for 6 weeks, and you're trying to remember which one had the fever and which one was the smoker with the productive cough.

Your notes need to capture enough detail to rule out serious causes, justify treatment decisions, and keep insurance happy, but you've got 15 more patients waiting.

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, documenting a cough visit was all over the place.

One provider might write "patient has cough - gave cough syrup" while another would write half a page about every possible differential diagnosis without actually documenting what they found.

There was no consistency, and good luck trying to figure out if the patient actually had concerning symptoms or not.

Then in the late 1960s, Dr. Lawrence Weed came along and created the Problem-Oriented Medical Record with SOAP notes as its foundation.

His brilliant idea was simple: give everyone the same template so documentation actually makes sense to whoever reads it next.

Here's what Dr. Weed came up with:

• S (Subjective): What the patient tells you about their cough and associated symptoms
• O (Objective): What you observe during the exam - vital signs, lung sounds, appearance
• A (Assessment): Your clinical judgment about what's causing the cough
• P (Plan): Your treatment plan and follow-up strategy

This format became essential for cough documentation because you need to capture duration, character, associated symptoms, and red flags - all in a way that clearly shows your clinical reasoning.

How to Write Cough SOAP Notes: My Recommended Approach

When I started working with urgent care and primary care providers, I noticed they'd get bogged down trying to document every tiny detail about a simple cough.

Then I learned something that changed everything:

"Get the essentials first. Everything else is bonus."

Document duration, character (dry vs productive), fever presence, associated symptoms, and lung sounds. That's your foundation. Those five things tell you if it's viral, bacterial, or something to worry about.

I built soapnotes.doctor around this principle of capturing what actually matters.

There are technically two ways you can approach cough 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 captures the key details without the tedious typing, and it never forgets to document red flags.

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 it knows what insurance companies look for in cough documentation - duration, severity, complications, and justification for antibiotics or imaging.

And if you need to add details later, the tailorr feature lets you edit, approve, add context, and copy straight to your EHR.

Write Manually

Maybe you prefer typing it out yourself. Here's how to do it efficiently without missing the important stuff.

1. S - Subjective

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

This section should document the key characteristics that help you narrow down the diagnosis.

Purpose: Document the patient's description of their cough and associated symptoms.

What to include:

• Duration of cough (acute less than 3 weeks, subacute 3-8 weeks, chronic more than 8 weeks)
• Character (dry vs productive, sputum color if productive)
• Timing (constant vs intermittent, worse at night or morning)
• Associated symptoms (fever, shortness of breath, chest pain, nasal congestion)
• Aggravating/relieving factors
• Previous treatments tried
• Relevant medical history and exposures

Examples:

"Patient reports dry, hacking cough for 5 days, worse at night. Rates severity 6/10. Denies fever, chills, or shortness of breath. Mild nasal congestion and sore throat for past week, improving. No chest pain or hemoptysis. Tried over-the-counter cough suppressant with minimal relief. No sick contacts. Non-smoker. No chronic medical conditions."

"Patient presents with productive cough for 10 days producing yellow-green sputum. Reports fever to 101.5°F at home yesterday. Describes chest discomfort with deep breaths and coughing fits. Increasing shortness of breath with exertion over past 3 days. Tried guaifenesin without improvement. History of COPD, former smoker with 30 pack-year history."

2. O - Objective

This is where you document what you observe and measure.

The objective section records your clinical findings that support or refute your diagnostic suspicions.

Purpose: Document measurable, observable findings from your physical examination.

What to include:

• Vital signs (especially temperature, respiratory rate, oxygen saturation)
• General appearance
• Lung examination (breath sounds, wheezes, crackles, rhonchi)
• Oropharynx examination
• Other relevant exam findings (nasal mucosa, lymph nodes, skin)

Examples:

"Vitals: Temp 98.4°F, BP 118/76, HR 72, RR 16, O2 sat 99% on room air. General: Alert, well-appearing, no distress. HEENT: Nasal mucosa mildly erythematous with clear discharge, posterior pharynx mildly erythematous without exudate, no tonsillar enlargement. Neck: No cervical lymphadenopathy. Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi, good air movement. Cardiovascular: Regular rate and rhythm."

"Vitals: Temp 100.8°F, BP 132/84, HR 98, RR 22, O2 sat 91% on room air. General: Appears ill, mild respiratory distress, speaking in full sentences. HEENT: Oropharynx clear. Lungs: Decreased breath sounds right lower lobe, crackles right base, bronchial breath sounds noted, dullness to percussion right lower lung field. No wheezes. Cardiovascular: Tachycardic, regular rhythm."

3. A - Assessment

This section is your professional clinical assessment of what's causing the cough.

Purpose: Connect the subjective and objective findings into a working diagnosis.

Key Principle: Be specific about your reasoning and rule out red flags.

What to include:

• Your diagnosis or differential diagnosis
• Duration classification (acute, subacute, chronic)
• Severity assessment
• Complications if present
• What you've ruled out

Examples:

"Acute viral upper respiratory infection with post-nasal drip. Cough duration 5 days consistent with viral etiology. No fever, normal vital signs, and clear lung exam rule out bacterial pneumonia. Patient does not meet criteria for antibiotic therapy. Expected self-limited course."

"Community-acquired pneumonia, right lower lobe. Clinical presentation of productive cough with purulent sputum, fever, dyspnea, and exam findings of decreased breath sounds, crackles, and dullness to percussion are consistent with bacterial pneumonia. Hypoxia with O2 sat 91% indicates moderate severity. Patient meets criteria for outpatient antibiotic therapy."

4. P - Plan

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

Purpose: Document your management strategy with clear justification.

Length: Be specific about treatments and when to return.

What to include:

• Medications prescribed with reasoning
• Symptomatic treatments recommended
• Patient education provided
• Follow-up plan and timing
• Red flags for earlier return

Examples:

"Symptomatic treatment for viral URI. Recommended increased fluid intake, rest, and honey for cough suppression. May use over-the-counter dextromethorphan for nighttime cough if needed. Advised use of humidifier and saline nasal spray for congestion. Educated on expected 7-10 day course. Return precautions discussed: return if fever develops, shortness of breath, cough persists beyond 3 weeks, or symptoms worsen. No antibiotics indicated at this time."

"Initiated azithromycin 500mg day 1, then 250mg days 2-5 for community-acquired pneumonia. Recommended acetaminophen 650mg every 6 hours for fever and discomfort. Advised increased oral fluid intake and rest. Educated on pneumonia warning signs including worsening shortness of breath, chest pain, or confusion. Follow-up in 48-72 hours to reassess response to therapy. Chest X-ray ordered to confirm diagnosis and assess severity. Return sooner or go to ED if difficulty breathing, altered mental status, or symptoms significantly worsen."

Complete Cough SOAP Note Examples

Now let's look at three complete examples that show different common cough presentations.

Example 1: Acute Viral Upper Respiratory Infection

Patient: 32-year-old female
Visit Type: Urgent care visit
Chief Complaint: Cough for 1 week

S – Subjective:

Patient presents with cough that started 7 days ago. Describes it as initially dry, now occasionally producing small amounts of clear to white mucus. Cough is worse at night, disrupting sleep 2-3 times nightly. Rates cough severity as 5/10. Initially had sore throat and nasal congestion which have improved over past few days. Denies fever - has been checking temperature daily, highest reading 99.1°F three days ago. No shortness of breath or difficulty breathing. No chest pain except mild soreness from coughing fits. Denies hemoptysis. Tried over-the-counter cough syrup (guaifenesin) with minimal relief. Also taking ibuprofen occasionally for body aches. Reports several coworkers have had similar illness over past 2 weeks. No recent travel. Non-smoker, no vaping. No significant past medical history. Up to date on vaccines including COVID-19.

O – Objective:

Vitals: BP 118/74, HR 76, Temp 98.6°F, RR 14, O2 sat 99% on room air
General: Alert and oriented, well-appearing, no acute distress, speaking comfortably in full sentences
HEENT: Conjunctivae clear, nasal mucosa mildly erythematous with minimal clear discharge, oropharynx mildly erythematous without exudate or tonsillar enlargement, tympanic membranes clear bilaterally
Neck: Supple, no cervical lymphadenopathy, no thyromegaly
Lungs: Clear to auscultation bilaterally in all fields, no wheezes, rales, rhonchi, or stridor, good air exchange, symmetric expansion, resonant to percussion
Cardiovascular: Regular rate and rhythm, no murmurs
Skin: No rash

A – Assessment:

32-year-old female with acute viral upper respiratory infection manifesting as post-viral cough. Symptom duration of 7 days with initial upper respiratory symptoms (sore throat, congestion) now improving is consistent with typical viral URI course. No fever currently, normal vital signs including oxygen saturation, and clear lung examination effectively rule out bacterial pneumonia. Character of cough (initially dry, now minimally productive with clear sputum) and absence of systemic symptoms suggest viral rather than bacterial etiology. Patient does not meet any criteria for antibiotic therapy per current guidelines. Expected natural resolution within 1-2 weeks.

P – Plan:

Provided education on natural course of viral URI with explanation that cough can persist 2-3 weeks even after other symptoms resolve. Recommended symptomatic management: honey (1-2 teaspoons) as needed for cough suppression, particularly effective at bedtime for nighttime cough. May use over-the-counter dextromethorphan 15-30mg every 4-6 hours if honey insufficient, especially for sleep. Encouraged increased fluid intake (8-10 glasses daily) to thin secretions. Recommended use of humidifier in bedroom at night. Saline nasal spray may help with residual congestion. Continue ibuprofen 400mg every 6 hours as needed for discomfort. No antibiotics prescribed as patient has clear viral etiology without bacterial complications. Discussed when antibiotics are appropriate vs harmful (antibiotic resistance, side effects). Return precautions reviewed: seek care if fever develops above 100.4°F, shortness of breath or difficulty breathing, chest pain, cough with blood, symptoms significantly worsen, or if cough persists beyond 3 weeks. Patient verbalized understanding and agreement with plan. Reassured patient this is expected to resolve on its own with time and symptomatic treatment.

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Example 2: Acute Bronchitis with Antibiotic Consideration

Patient: 58-year-old male
Visit Type: Primary care follow-up
Chief Complaint: Persistent cough, feeling worse

S – Subjective:

Patient presents with cough for 12 days that is worsening rather than improving. Initially started as dry cough with runny nose and body aches, thought it was "just a cold." Over past 4 days, cough has become productive of thick yellow sputum, producing approximately tablespoon of sputum with each coughing episode. Reports subjective fever "feeling hot and sweaty" but hasn't taken temperature. Increased fatigue and decreased energy over past 3 days. Now experiencing shortness of breath with moderate activity like walking up stairs or carrying groceries. Denies chest pain at rest but reports chest feels tight and sore from coughing. No hemoptysis. Tried over-the-counter cold medications without significant improvement. Has been taking acetaminophen which temporarily relieves body aches. Medical history significant for hypertension controlled on lisinopril and type 2 diabetes controlled on metformin. Former smoker, quit 5 years ago, 20 pack-year history. No known drug allergies.

O – Objective:

Vitals: BP 138/86, HR 92, Temp 100.6°F, RR 20, O2 sat 94% on room air
General: Appears mildly ill, frequent coughing during exam, able to complete sentences
HEENT: Oropharynx clear, no exudate
Neck: No lymphadenopathy
Lungs: Bilateral scattered rhonchi that clear somewhat with coughing, no focal consolidation appreciated, mild prolonged expiratory phase, no wheezes, occasional coarse breath sounds
Cardiovascular: Regular rate and rhythm, mildly tachycardic
Extremities: No edema, adequate perfusion

A – Assessment:

58-year-old male with acute bronchitis, 12-day duration now with worsening symptoms. Patient initially had viral URI symptoms, now with progression to productive cough with purulent sputum, low-grade fever, and mild hypoxia suggesting possible bacterial superinfection versus severe acute bronchitis. Physical exam reveals rhonchi consistent with bronchial inflammation but no focal findings to suggest pneumonia. Risk factors including former smoking history, diabetes, and age over 50 increase concern for bacterial etiology. While most acute bronchitis is viral and self-limited, patient's clinical deterioration after initial improvement, persistent fever, purulent sputum, and comorbidities warrant consideration of antibiotic therapy. Mild hypoxia (94% O2 saturation) is concerning but does not require hospitalization at this time.

P – Plan:

Given clinical deterioration, comorbidities, and duration of symptoms with purulent sputum production, will initiate antibiotic therapy with azithromycin 500mg today, then 250mg daily for 4 additional days (Z-pack). Prescribed benzonatate 100mg three times daily for cough suppression as patient experiencing significant cough paroxysms interfering with sleep and daily activities. Continue acetaminophen 650mg every 6 hours as needed for fever and discomfort. Recommended increased fluid intake to 8-10 glasses daily to thin secretions. Advised use of humidifier to ease breathing and cough. Patient educated on importance of completing full antibiotic course even if feeling better. Close follow-up: patient to contact office in 48-72 hours to report progress, will call to check on improvement. Strict return precautions: go to ED or urgent care if worsening shortness of breath, chest pain, confusion, coughing up blood, oxygen saturation drops below 90% (provided instructions on home pulse oximetry if available), or if high fever persists beyond 48 hours of antibiotics. If not significantly improved in 5 days, patient to return for reevaluation and possible chest X-ray to rule out pneumonia. Patient verbalized understanding of treatment plan and warning signs requiring immediate attention. Encouraged smoking cessation maintenance and provided resources.

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Example 3: Chronic Cough Requiring Workup

Patient: 45-year-old female
Visit Type: Primary care visit
Chief Complaint: Cough for 2 months

S – Subjective:

Patient presents with persistent dry cough for approximately 8-9 weeks. Describes cough as non-productive, frequent throughout day but particularly troublesome at night and first thing in morning. Denies fever, chills, or night sweats throughout this entire period. No shortness of breath with exertion, no chest pain or tightness. No hemoptysis. Reports sensation of "tickle in throat" that triggers coughing episodes. Cough occasionally triggered by talking, laughing, or exposure to perfumes and strong odors. Initially thought it was related to seasonal allergies but allergy symptoms have resolved while cough persists. Tried multiple over-the-counter cough suppressants without benefit. No recent upper respiratory infections or sick contacts. No unintentional weight loss. Denies heartburn but occasionally has sour taste in mouth, especially in morning. No difficulty swallowing. Medical history includes well-controlled hypertension on lisinopril 10mg daily for past year (started approximately 10 weeks ago). Non-smoker, no vaping. Works in office setting, no known occupational exposures. No recent travel. No history of asthma or lung disease. Mother has asthma.

O – Objective:

Vitals: BP 124/78, HR 70, Temp 98.2°F, RR 14, O2 sat 98% on room air, BMI 28
General: Well-appearing, no distress between coughing episodes
HEENT: Oropharynx clear, no posterior pharyngeal erythema or cobblestoning, no tonsillar enlargement
Neck: No thyromegaly, no cervical lymphadenopathy
Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi, or stridor, good air exchange, normal percussion
Cardiovascular: Regular rate and rhythm, no murmurs
Chest X-ray (performed today): Clear lung fields, no infiltrates, masses, or effusions, normal cardiac silhouette

A – Assessment:

45-year-old female with chronic cough (duration greater than 8 weeks) requiring evaluation for underlying etiology. Given dry, non-productive nature of cough, absence of systemic symptoms, clear chest X-ray, and normal physical examination, most likely etiologies include: (1) ACE inhibitor-induced cough (timing correlates with lisinopril initiation 10 weeks ago), (2) cough-variant asthma (triggered by irritants, family history of asthma, responds to same pattern as asthma), (3) gastroesophageal reflux disease/laryngopharyngeal reflux (morning sour taste, nocturnal cough), or (4) upper airway cough syndrome/post-nasal drip (throat tickle sensation). ACE inhibitor-induced cough is leading consideration given temporal relationship and is well-documented side effect occurring in 5-35% of patients, typically developing 1-4 weeks after initiation but can occur months later. This is diagnosis of exclusion requiring discontinuation of ACE inhibitor and observation.

P – Plan:

Will pursue stepwise evaluation approach for chronic cough. First intervention: discontinue lisinopril as ACE inhibitor-induced cough is most likely etiology given timing. Switching antihypertensive to losartan 50mg daily (ARB class, does not cause cough). ACE inhibitor cough typically resolves within 1-4 weeks of discontinuation. Patient to monitor blood pressure at home and keep log. If cough persists after 4 weeks off ACE inhibitor, will pursue additional workup. Prescribed trial of omeprazole 20mg daily before breakfast for 2 weeks to empirically treat potential GERD contribution to cough. Recommended lifestyle modifications: elevate head of bed 6 inches, avoid eating within 3 hours of bedtime, reduce caffeine and acidic foods. If cough does not improve with ACE inhibitor discontinuation and PPI trial, will consider: (1) pulmonary function tests with bronchoprovocation to evaluate for cough-variant asthma, (2) empiric trial of inhaled corticosteroid if PFTs suggest asthma component, (3) referral to ENT for laryngoscopy if concern for laryngopharyngeal reflux persists. Follow-up in 4 weeks to reassess cough after medication change. Patient to call sooner if develops new symptoms including fever, shortness of breath, wheezing, chest pain, hemoptysis, or if cough significantly worsens. Educated on expected timeline for ACE inhibitor cough resolution. Patient expressed understanding and relief at having evaluation plan. Reassured that chronic cough is concerning but chest X-ray showing clear lungs is reassuring, and systematic approach should identify cause.

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Additional Tips for Cough SOAP Notes

Duration is Critical: Always document exactly how long the cough has been present. This determines your differential diagnosis and workup intensity.

Character Matters: Dry vs productive, and if productive, what color? This helps distinguish viral from bacterial causes.

Red Flags: Document presence or absence of fever, hemoptysis, weight loss, night sweats, dyspnea. These drive your urgency and workup.

Antibiotic Justification: If prescribing antibiotics, document specific criteria met (purulent sputum, fever, clinical deterioration, comorbidities). If not prescribing, document why viral etiology is most likely.

Medication History: Always document what over-the-counter treatments have been tried. This shows you're not just reflexively prescribing.

Timeline Expectations: Document what you told the patient about expected resolution time. This prevents unnecessary return visits.

Return Precautions: Always document when patient should return or seek emergency care. This protects you legally and ensures patient safety.

Implementing structured SOAP notes for cough visits ensures you capture the essential differentiating features, justify your treatment decisions, and document appropriate safety precautions for follow-up.