Complete Guide to Pediatric Asthma SOAP Note Examples for Healthcare Providers

If you've ever struggled to document pediatric asthma visits in a way that captures symptom control while meeting insurance requirements for medications and specialist referrals, this guide is for you.

I've talked to countless pediatricians, family physicians, and allergists who spend significant time documenting asthma visits to justify controller medications, emergency interventions, and pulmonology referrals.

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

They want to see clear assessment of asthma control, proper classification of severity, evidence that step-wise therapy is being followed, and documentation of patient/family education.

That's exactly why I built SOAP Notes Doctor to handle the documentation burden while you focus on optimizing asthma management for your young patients.

In this article, I'll show you exactly how to write pediatric asthma SOAP notes that meet insurance standards, with real examples you can use as templates.

🧾 What SOAP Notes Really Are (And Why They Matter for Pediatric Asthma)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose in asthma 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 pediatric asthma specifically, SOAP notes are critical because they demonstrate:

• Clear assessment of asthma control and symptom frequency
• Appropriate severity classification and treatment step
• Medical necessity for controller medications and biologics
• Trigger identification and environmental control measures
• Patient and family education on medication technique and action plans
• Justification for specialist referrals or emergency interventions

SOAP stands for:

• S — Subjective: What the patient/parent reports about symptoms, rescue inhaler use, nighttime awakenings, activity limitations, triggers, and medication adherence.
• O — Objective: Your clinical findings including vitals (especially respiratory rate and oxygen saturation), respiratory effort, lung auscultation, peak flow or spirometry results, and response to treatments.
• A — Assessment: Your clinical diagnosis with asthma control classification (well-controlled, not well-controlled, or very poorly controlled), severity level, and any complicating factors.
• P — Plan: Your treatment plan including medication adjustments following step-wise approach, trigger avoidance, asthma action plan review, inhaler technique assessment, 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 demonstrates appropriate asthma management.

How You Can Approach Pediatric Asthma SOAP Notes

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

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

1. Traditional, Manual Documentation

This is the classic method: typing out each section after the visit. It works if you have strong clinical documentation skills and time built into your schedule. The challenge is it's time-consuming, and ensuring you capture all required elements (symptom frequency, nighttime awakenings, activity limitation, rescue inhaler use) can be easy to miss when rushed.

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 never miss critical components that insurance companies require for asthma medication approvals.

How to Make Pediatric Asthma SOAP Notes Faster

One of the biggest complaints I hear from pediatric providers is how asthma documentation eats into their already packed schedules.

You've just finished back-to-back sick visits and well-checks, including several asthma follow-ups, and instead of moving efficiently through your day, you're stuck documenting detailed asthma control assessments for each patient.

The pressure is real: make them too brief and you risk denials for controller medications or step-up therapy; make them too detailed and you've just added significant time to an already long day.

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 back to seeing patients without documentation backlog

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, but without manually typing every detail.

Maybe you noted specific findings?

"Using albuterol 3-4 times per week, waking up twice last week with cough, missed one soccer practice due to wheeze, mom forgot spacer technique, lungs clear today, peak flow 85% predicted."

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

Example 1: Asthma Follow-Up, Well-Controlled

Patient: 8-year-old male
Diagnosis: Persistent asthma, currently well-controlled
Chief Complaint: Routine asthma follow-up
Visit: Established patient check

S – Subjective:

Mother reports patient doing well overall on current asthma regimen. Using fluticasone inhaler twice daily as prescribed with good adherence. Rescue albuterol use less than twice per week, primarily before soccer practice as pre-treatment. No nighttime awakenings due to asthma symptoms in past month. No school absences related to asthma. Able to participate fully in sports and physical activities without limitation. No recent colds or respiratory infections. Denies exposure to secondhand smoke. Known triggers include exercise and seasonal allergies (spring pollen). Patient reports some nasal congestion but no significant impact on daily activities. Last urgent care visit or ED visit for asthma was over 1 year ago. Mother demonstrates good understanding of asthma action plan.

O – Objective:

Vital Signs: Temp 98.4°F, HR 88, RR 18, O2 sat 99% on room air, BP 102/64
General: Alert, active, in no respiratory distress, speaking in full sentences
HEENT: Nasal mucosa mildly edematous, no nasal polyps, oropharynx clear
Chest: Clear breath sounds bilaterally, no wheezing, no prolonged expiratory phase, good air movement, no accessory muscle use
Peak Flow: 240 L/min (90% of personal best, 92% predicted for height)
Inhaler Technique: Observed metered-dose inhaler use with spacer, excellent technique demonstrated

A – Assessment:

Persistent asthma, well-controlled on current low-dose ICS therapy. Patient meeting all criteria for well-controlled asthma: symptoms less than 2 days per week, no nighttime awakenings, no interference with normal activity, rescue inhaler use less than 2 days per week, normal lung function. Currently on Step 2 therapy per NAEPP guidelines. Mild allergic rhinitis, seasonal.

P – Plan:

Continue fluticasone 44 mcg 2 puffs twice daily. Continue albuterol MDI 2 puffs as needed for symptoms or before exercise. Reinforced importance of daily controller medication even when feeling well. Reviewed asthma action plan with family, no changes needed. Discussed using albuterol 15-20 minutes before sports activities to prevent exercise-induced symptoms. For seasonal allergies, recommended daily antihistamine (cetirizine) during pollen season. Encouraged continued environmental controls: dust mite covers, no pets in bedroom, HEPA filter in bedroom. Follow-up in 6 months for routine asthma check or sooner if control worsens. Instructed to call if rescue inhaler needed more than twice per week, any nighttime awakenings, or difficulty with activities. Patient and mother verbalized understanding of plan.

---

Example 2: Acute Asthma Exacerbation, Moderate Severity

Patient: 5-year-old female
Diagnosis: Asthma exacerbation
Chief Complaint: Cough and wheezing for 2 days
Visit: Urgent sick visit

S – Subjective:

Mother reports patient developed cold symptoms 4 days ago with runny nose and mild cough. Cough worsened over past 2 days, now producing wheezing audible to parents. Patient has been using albuterol every 3-4 hours at home with temporary relief. Woke up last night coughing three times. Today unable to finish playing with friends due to shortness of breath. Denies fever. Some decreased appetite and fluid intake. Patient has history of asthma with previous exacerbations requiring oral steroids, last occurrence 6 months ago. Usually uses albuterol only occasionally between exacerbations. Not currently on controller medication (previously discontinued due to good control). No recent environmental changes or new exposures.

O – Objective:

Vital Signs: Temp 98.8°F, HR 118, RR 32, O2 sat 94% on room air
General: Mild respiratory distress, able to speak in phrases but not full sentences
Chest: Diffuse expiratory wheezing bilaterally, prolonged expiratory phase, mild intercostal retractions, fair air movement throughout
Peak Flow: Unable to perform adequately due to age and distress
Post-Treatment: After albuterol nebulizer treatment in office, RR decreased to 26, O2 sat improved to 97%, wheezing diminished but still present, retractions resolved, patient more comfortable

A – Assessment:

Acute asthma exacerbation, moderate severity, triggered by upper respiratory infection. Patient showing incomplete response to rescue albuterol with persistent symptoms. This represents third exacerbation requiring intervention in past year, indicating inadequate asthma control and need for controller therapy. Viral upper respiratory infection as triggering factor.

P – Plan:

Administered albuterol nebulizer 2.5mg in office with improvement. Prescribed prednisolone 30mg (2mg/kg) daily for 5 days, no taper needed for short course. Instructed to continue albuterol every 4 hours while awake for next 48 hours, then space to every 6 hours, then as needed based on symptoms. Given pattern of recurrent exacerbations, initiated daily controller therapy with fluticasone 44mcg 2 puffs twice daily starting today. Provided spacer and demonstrated proper MDI technique with mother and patient. Reviewed warning signs requiring emergency care: worsening breathing, speaking only in single words, blue lips, extreme fatigue, or no improvement with albuterol. Instructed to follow up in 3-5 days for reassessment or sooner if worsening. If symptoms not improving in 24-48 hours or if needing albuterol more frequently than every 4 hours, to call office or go to ED. Once acute exacerbation resolved, will reassess need for ongoing controller therapy at follow-up visit. Family verbalized understanding and will call with concerns.

---

Example 3: Poorly Controlled Asthma, Step-Up Therapy Needed

Patient: 11-year-old male
Diagnosis: Persistent asthma, poorly controlled
Chief Complaint: Frequent asthma symptoms despite medications
Visit: Asthma management visit

S – Subjective:

Patient and father report ongoing asthma symptoms despite using fluticasone inhaler daily. Using rescue albuterol 4-5 times per week, primarily for symptoms during school day and with physical activity. Waking at night with cough and chest tightness 2-3 times per week, requiring albuterol. Has missed 4 days of school in past 2 months due to asthma symptoms. Unable to complete full gym class without needing breaks. Father admits adherence to controller medication has been inconsistent—estimates patient takes morning dose about 5 days per week and often forgets evening dose. Known triggers include exercise, cold air, and pet dander (has dog at home that sleeps in patient's room). No recent ED visits but has used urgent care twice in past 3 months. Family history significant for mother with asthma.

O – Objective:

Vital Signs: Temp 98.6°F, HR 92, RR 20, O2 sat 98% on room air
General: Well-appearing, comfortable at rest, no acute distress
Chest: Scattered end-expiratory wheezes bilaterally, slightly prolonged expiratory phase, good air movement, no retractions
Spirometry: FEV1 78% predicted (below 80% indicating impairment), FEV1/FVC ratio 0.76, bronchodilator response showing 15% improvement post-albuterol (significant reversibility)
Inhaler Technique Assessment: Patient demonstrates poor MDI technique—not shaking inhaler, inadequate breath-hold, no spacer use

A – Assessment:

Persistent asthma, poorly controlled (not well-controlled) on current therapy. Patient meets criteria for poor control: daytime symptoms more than 2 days per week, nighttime awakenings more than 2 times per month, significant interference with normal activities, rescue inhaler use more than 2 days per week, lung function less than 80% predicted. Contributing factors include suboptimal medication adherence and improper inhaler technique. Currently on Step 2 therapy with inadequate response—requires step-up to Step 3. Environmental exposures (pet dander) likely contributing to poor control.

P – Plan:

Medication Adjustment: Step up therapy per NAEPP guidelines. Discontinue fluticasone monotherapy. Started combination fluticasone-salmeterol 100/50mcg diskus 1 puff twice daily (Step 3 therapy combining low-dose ICS with LABA). Continue albuterol as needed for symptoms, goal to reduce frequency with better control. Provided written asthma action plan with clear zones and instructions.

Adherence and Technique: Spent time with patient and father discussing importance of twice-daily controller medication even when feeling well. Suggested setting phone reminders for morning and evening doses. Corrected inhaler technique—provided spacer for albuterol MDI and demonstrated proper diskus technique. Had patient demonstrate back technique until proficient.

Environmental Control: Strongly recommended removing dog from bedroom at minimum, ideally from home given significant pet dander trigger. Discussed using HEPA filter, allergen-proof bedding covers, and weekly hot water washing of bedding.

Monitoring: Instructed patient to keep symptom diary tracking rescue inhaler use, nighttime awakenings, and activity limitations. Follow-up in 2-4 weeks to reassess control on new regimen. If no improvement, will consider referral to pediatric pulmonology and possible allergy testing. Discussed that if control not achieved with Step 3 therapy, may need to consider additional controller or evaluate for alternative diagnoses.

Education: Reviewed warning signs of severe exacerbation requiring emergency care. Instructed to call if needing albuterol more than every 4 hours or if symptoms rapidly worsening. Patient and father verbalized understanding of new treatment plan and importance of adherence.

---

Key Components Insurance Companies Look For in Pediatric Asthma SOAP Notes

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

1. Asthma Control Assessment

Document the four key control parameters: daytime symptom frequency, nighttime awakenings, activity limitation, and rescue inhaler use frequency (more than 2 days per week indicates poor control).

2. Step-Wise Therapy Justification

Clearly document current treatment step and rationale for any changes. Insurance wants to see you're following NAEPP or GINA guidelines for step-up or step-down therapy.

3. Severity Classification

Document whether asthma is intermittent, mild persistent, moderate persistent, or severe persistent—this drives medication coverage decisions.

4. Lung Function Measurements

Peak flow or spirometry results (when age-appropriate) demonstrate objective assessment and track treatment response.

5. Trigger Identification and Avoidance

Document known triggers and environmental control measures recommended or implemented.

6. Medication Adherence and Technique

Document adherence assessment and inhaler technique observation—poor control may be due to these factors rather than need for medication escalation.

7. Patient/Family Education

Document asthma action plan review, medication education, and trigger avoidance counseling—prevents readmissions and demonstrates quality care.

Common Mistakes to Avoid

Vague Symptom Frequency: Instead of "occasional symptoms," document specific frequency: "symptoms 3 days per week" or "nighttime awakenings twice in past month."

Missing Rescue Inhaler Use Frequency: This is one of the four key control parameters—always ask and document how often albuterol is needed.

No Adherence Assessment: Document medication adherence, don't assume poor control means need for step-up therapy without evaluating if current medications are being taken properly.

Forgetting Inhaler Technique: Observing and documenting inhaler technique is essential—improper technique causes treatment failure.

Inadequate Step-Wise Therapy Documentation: When changing medications, reference which treatment step you're moving to and why based on control assessment.

No Trigger Discussion: Document known triggers and environmental modifications recommended—this shows comprehensive management.

Missing Asthma Action Plan: Document that you reviewed or provided written action plan—insurance and quality metrics often require this.

Tips for Efficient Documentation

Use Standard Control Assessment Questions: Ask the same four questions every visit: symptom frequency, nighttime awakenings, activity limitation, rescue inhaler use.

Document Treatment Step: Simply state "currently on Step 2 therapy" or "stepping up to Step 3"—this immediately clarifies treatment rationale.

Include Specific Numbers: "Using albuterol 4 times per week" is better than "frequent rescue inhaler use."

Reference Guidelines: Brief mention of "per NAEPP guidelines" or "following step-wise approach" strengthens documentation.

Template Common Elements: Create templates for well-controlled follow-ups versus exacerbations versus poorly controlled visits.

Final Thoughts

Pediatric asthma SOAP notes don't need to be overwhelming.

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

The key is having a system that captures essential control parameters, justifies treatment decisions, and documents proper asthma management without making you feel like documentation is taking time away from patient care.

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

Your time is better spent educating families about asthma management and optimizing treatment 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.

---

Ready to simplify your pediatric asthma documentation?
Visit soapnotes.doctor and get your first notes generated in minutes.