Tips to Write SOAP Notes for Pneumonia Like a Genius | With Samples

Sample SOAP Note for Pneumonia

Pneumonia SOAP notes can feel like walking a tightrope.

Miss some details, and you risk miscommunicating patient state, or worse, run into compliance issues. Over-document, and you have good paperwork when you could at least take a break.

So what's the savior? Or who's the savior? How can you document pneumonia or at least learn to document them better?

Let's go over that.

Quick tip: I built soapnotes.doctor, so professionals never have to worry about how they write SOAP notes. You have excellent notes every good time by tapping buttons, while being 100% compliant. Head over to soapnotes.doctor to get started.

A Quick SOAP Notes Backstory

Clinical encounters are naturally chaotic.

Patients share symptoms in whatever order they remember them, physical exams reveal findings that may or may not relate to the chief complaint.

On the other hand, treatment decisions require synthesizing multiple types of information quickly and accurately.

Somebody had to do something, or we'd have documentation more littered than it already is, today.

Dr. Lawrence Weed, at the University of Vermont, introduced SOAP notes in his Problem-Oriented Medical Record system. This was in the 60s.

It was very much welcomed and became the game-changer at the time.

For instance, without SOAP notes, imagine being called 4 months after a session by a lawyer who wants to know exactly what interventions you used with a client back in March.

Or maybe you're trying to hand off a client to another professional and you need to explain three years of progress in a way that actually makes sense.

SOAP notes brought order to this chaos.

Why It Works:

• Subjective sections force you to really listen to your patients
• Objective findings keep you honest and thorough
• Assessment components make your thinking visible
• Plan sections ensure follow-through

The Right Way to Approach SOAP Notes in 2025

If you want your stuff quick, consistent, and compliant, my one answer…use soapnotes.doctor.

To create a quick, consistent and compliant note all you have to do is to use the record button in a session. Use the "save session" button when you're done. Voila.

Soapnotes.doctor processes in a short time and hands you over your output.

Now for whatever reason you need to edit, you can easily do that and use the save button afterwards. Want to use a different medical pattern? Perhaps your practice uses bullet points over paragraphs.

We built the tailorr feature for this.

Soapnotes.doctor was built on the bedrock of consistency, security, and coherence.

This is the reason we have AES encryption that ensures patient data can only ever be viewed by practitioners.

It remains gibberish, decrypted to everyone else including soapnotes.doctor.

It's for the same reason why your records are deleted the moment you're done using the recording button.

Also you can delete notes at your liberty and they're wiped out to inexistence.

The same reason we're HIPAA compliant.

Security at its peak.

Strategy #2: The Three-Layer System

Maybe you still prefer writing everything by hand.

That's fine.

Here's the system that'll keep you sane while doing this:

Layer 1: Build Your Pneumonia Template Before the Patient Walks In

Stop reinventing the wheel every time you see a pneumonia case.

Create a respiratory-focused framework and use it consistently:

Subjective: "Patient reports [chief complaint] x [duration]. Associated symptoms: [cough/SOB/chest pain/fever]. Severity scale: [1-10]. Quote that tells the whole story: [their exact words about how they feel]."

Objective: Make yourself a comprehensive pneumonia checklist:

• Vitals (temp, BP, HR, RR, O2 sat on room air vs. supplemental oxygen)
• General appearance (distressed? using accessory muscles? positioning?)
• HEENT (any upper respiratory signs? neck lymph nodes?)
• Pulmonary exam (inspection, palpation, percussion, auscultation—be specific about location)
• Cardiovascular (heart sounds, peripheral edema, JVD if relevant)
• Skin (color, temperature, capillary refill, any rashes?)
• Neurological (mental status changes? confusion in elderly?)
• Lab values (CBC with diff, BMP, blood cultures if obtained)
• Imaging results (chest X-ray findings, CT if done)
• Any point-of-care tests (sputum gram stain, rapid flu, COVID, etc.)

Assessment: What's really happening here? Break this down systematically:

• Primary diagnosis with confidence level (Community-acquired pneumonia, likely bacterial vs. "Rule out pneumonia, consider viral bronchitis")
• Severity assessment (mild, moderate, severe—use CURB-65 or PSI if your facility requires it)
• Likely organism (typical bacterial vs. atypical vs. viral—what's your clinical reasoning?)
• Complications present or at risk for (respiratory failure, sepsis, pleural effusion, etc.)
• Response to treatment if already started (improving, stable, worsening)
• Comorbidities that affect management (COPD, heart failure, immunocompromised status)
• Social factors affecting care (home support, compliance concerns, follow-up ability)

The goal is to have a pattern you'll stick that makes things go on the fly.

Layer 2: Create Shorthand

This is where most people crash and burn.

They try to write war-and-peace-length notes during the encounter and miss the actual clinical details because they're busy scribbling.

Always—and always start a session with a shorthand system that keep you fast. The goal is to be efficient.

So, in our case, develop respiratory abbreviations that make sense to you:

• "SOB++" means significant dyspnea with visible distress
• "Rhonchi→clear" means wet sounds that cleared with coughing
• "O2 req↑" means increasing oxygen requirements since last assessment
• "Abx response++" means clear improvement on current antibiotic regimen
• "WOB+" means increased work of breathing with accessory muscle use
• "Dullness LLL" means percussion dullness in left lower lobe
• "Egophony+" means positive egophony suggesting consolidation

Make sure you're consistent with this.

Don't write "crackles" one day and "rales" the next, then "fine creps" the day after that.

Pick your terminology and stick with it, or you'll be second-guessing your own notes when the patient comes back sicker.

Layer 3: The Post-Encounter Five-Minute Rule

Now, the moment your pneumonia patient leaves the room—while you can still hear them coughing down the hallway—sit down and turn your scribbles into actual medical documentation.

Not after your next three patients. Not during lunch when you're trying to remember if it was upper lobe or lower lobe consolidation. Not at 8 PM when you're wondering why you didn't just become an accountant.

Right. Now.

Five to seven minutes maximum.

Transform your shorthand into sentences that would make sense to the hospitalist covering your patient tonight.

Add your clinical reasoning.

Connect the dots between the patient's presentation and your antibiotic choice.

Explain why you think it's bacterial pneumonia versus viral respiratory illness.

Make it crystal clear that you're not just throwing antibiotics at every cough—you've got evidence-based reasoning behind every decision.

Your Assessment section should sound like it came from someone who actually understands respiratory pathophysiology, not someone who just memorized pneumonia treatment algorithms.

And please, for the love of everything sacred in medicine, don't just write "continue current management" in your Plan section.

Be specific. What are you monitoring for improvement? When will you reassess? What's your backup plan if the patient doesn't respond? What red flags should they watch for at home?

Conclusion

And if all of these feel like work…

Head over to soapnotes.doctor.