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?

Complete Pneumonia SOAP Note Examples

Now let's look at three complete examples that show you exactly how these notes should look in real practice.

Example 1: Community-Acquired Pneumonia - Outpatient Treatment

Patient: 52-year-old female
Visit Type: Urgent care visit
Chief Complaint: Cough, fever, and shortness of breath for 4 days

S – Subjective:

Patient presents with 4-day history of productive cough with yellow-green sputum, fever to 101.5°F at home, and progressively worsening shortness of breath. Reports sharp right-sided chest pain that worsens with deep breathing and coughing. States she felt "run down" for 2 days before cough started. Fever responds temporarily to acetaminophen but returns. Chills and night sweats present. Denies nausea, vomiting, or diarrhea. No recent travel or sick contacts. Works as elementary school teacher, multiple children in class recently absent with "flu-like illness." No history of pneumonia. Medical history: well-controlled hypertension on lisinopril. Non-smoker. Tried over-the-counter cough syrup without relief. Rates dyspnea 6/10, worse with exertion like climbing stairs.

O – Objective:

Vitals: Temp 100.8°F, BP 138/84, HR 98, RR 22, O2 sat 93% on room air
General: Appears mildly ill, frequent coughing during exam, mild respiratory distress
HEENT: Oropharynx clear, no tonsillar exudate, no lymphadenopathy
Lungs: Decreased breath sounds right lower lobe, dullness to percussion right base, bronchial breath sounds with egophony over right lower lung field, fine crackles right base, left lung clear
Cardiovascular: Tachycardic but regular, no murmurs
Skin: Warm, capillary refill less than 2 seconds
Labs: WBC 14,200 (elevated with left shift), CRP 85 mg/L (elevated)
Chest X-ray: Right lower lobe infiltrate consistent with pneumonia, no pleural effusion

A – Assessment:

52-year-old female with community-acquired pneumonia, right lower lobe, likely bacterial etiology given productive cough with purulent sputum, fever, leukocytosis, and lobar consolidation on imaging. CURB-65 score: 0 (low risk, appropriate for outpatient management). Patient hemodynamically stable with adequate oxygenation on room air. No signs of severe sepsis or respiratory failure. Pleuritic chest pain likely from pleural inflammation adjacent to pneumonic process. Risk factors include recent exposure to ill children in classroom setting.

P – Plan:

Started azithromycin 500mg day 1, then 250mg daily for 4 days (covers typical and atypical organisms for outpatient CAP). Prescribed benzonatate 100mg three times daily for cough suppression. Continue acetaminophen 650mg every 6 hours as needed for fever and pain. Encourage oral fluid intake 2-3 liters daily. Rest from work for 3-5 days. Follow-up in 48-72 hours for clinical reassessment or sooner if worsening symptoms. Strict return precautions: worsening shortness of breath, chest pain, high fever not responding to acetaminophen, confusion, or inability to tolerate oral intake. If no improvement in 48-72 hours, will consider chest X-ray repeat and possible antibiotic change to cover resistant organisms. Patient verbalized understanding of diagnosis, treatment plan, and warning signs.

---

Example 2: Hospital-Acquired Pneumonia - Inpatient Management

Patient: 68-year-old male
Visit Type: Hospital day 5, post-operative complication
Chief Complaint: New onset fever and respiratory distress

S – Subjective:

Patient is post-op day 5 from elective hip replacement surgery. Nursing reports patient developed fever overnight to 102.3°F. Patient reports new onset shortness of breath and productive cough with thick yellow sputum starting yesterday evening. Denies chest pain but reports general fatigue and decreased appetite. Patient had been progressing well with physical therapy until yesterday. Minimal ambulation past 48 hours due to fatigue. Patient received general anesthesia for surgery, was intubated briefly (extubated in recovery room). No prior history of pneumonia or chronic lung disease. Former smoker, quit 10 years ago, 20-pack-year history.

O – Objective:

Vitals: Temp 101.8°F, BP 148/86, HR 106, RR 26, O2 sat 88% on room air (94% on 4L NC)
General: Elderly male in moderate respiratory distress, using accessory muscles, speaking in short phrases
Lungs: Decreased breath sounds bilateral bases, coarse crackles left greater than right, dullness to percussion left base, bronchial breath sounds left lower lobe
Cardiovascular: Tachycardic, regular rhythm, no murmurs
Extremities: Surgical site clean and healing appropriately, minimal edema
Labs: WBC 16,800 with 12% bands, procalcitonin 2.4 ng/mL (elevated, suggestive of bacterial infection), BMP within normal limits
Chest X-ray: New left lower lobe consolidation, small left pleural effusion, comparison to admission film shows clear interval change
Sputum culture: Pending (collected this AM, gram stain shows gram-negative rods)

A – Assessment:

68-year-old male with hospital-acquired pneumonia (HAP), post-operative day 5, presenting with fever, hypoxemia, and new left lower lobe infiltrate. Likely bacterial etiology, concern for gram-negative organisms or MRSA given hospital-acquired nature and post-operative status. Risk factors include recent surgery with intubation, decreased mobility, advanced age, and smoking history. Patient requiring supplemental oxygen, meeting criteria for moderate-severe HAP. Small pleural effusion likely parapneumonic. No signs of septic shock at this time but requires close monitoring. CURB-65 score: 2 (moderate risk).

P – Plan:

Initiated broad-spectrum antibiotics: piperacillin-tazobactam 4.5g IV every 6 hours and vancomycin 1g IV every 12 hours (dosing per pharmacy recommendations based on renal function) to cover pseudomonas and MRSA. Will narrow based on culture results. Supplemental oxygen 4L NC to maintain O2 sat greater than 92%. Incentive spirometry every hour while awake to improve lung expansion. Aggressive pulmonary toilet including chest physiotherapy. Encourage ambulation with PT assistance to prevent further complications. IV fluids for hydration. Monitor vitals every 4 hours. Repeat chest X-ray in 48 hours to assess response. Consulted respiratory therapy for nebulized treatments and airway clearance. Consider thoracentesis if pleural effusion increases. Daily labs including CBC and BMP. Will reassess antibiotic regimen once culture and sensitivities return. ICU transfer criteria discussed with team: worsening hypoxemia despite oxygen supplementation, hemodynamic instability, or altered mental status. Patient and family updated on diagnosis and treatment plan, expressed understanding.

---

Example 3: Aspiration Pneumonia in Nursing Home Resident

Patient: 81-year-old female
Visit Type: Emergency department, transferred from nursing home
Chief Complaint: Altered mental status and increased work of breathing

S – Subjective:

Patient transferred from nursing home with reported altered mental status and respiratory distress. Per nursing home records and accompanying aide: patient has advanced dementia, mostly bedbound, requires assistance with all ADLs. Baseline mental status is disoriented but conversant. Today found more lethargic than usual, difficult to arouse. Noted to have increased respiratory rate and low oxygen saturation on routine vital checks. Nursing staff reports patient had episode of coughing and choking during lunch yesterday (pureed diet due to known dysphagia). No documented aspiration event but suspicious given timing. Patient unable to provide reliable history due to altered mental status. Medical history significant for dementia, previous CVA with residual right-sided weakness, hypertension, type 2 diabetes. Recent weight loss noted in nursing home records.

O – Objective:

Vitals: Temp 100.2°F, BP 108/62, HR 112, RR 28, O2 sat 86% on room air (91% on 6L NC)
General: Elderly, cachectic female, lethargic but arousable to voice, moderate respiratory distress
HEENT: Dry mucous membranes, poor dentition
Neck: Supple, no JVD
Lungs: Coarse rhonchi bilateral lower lobes more prominent on right, bronchial breath sounds right base, decreased air movement, using accessory muscles
Cardiovascular: Tachycardic, regular rhythm
Abdomen: Soft, hypoactive bowel sounds
Neurological: Lethargic, oriented to person only, right-sided weakness consistent with previous stroke, no focal deficits beyond baseline
Labs: WBC 18,400 with left shift, BUN 42 (elevated), Creatinine 1.6 (elevated from baseline 1.1), glucose 210 mg/L, lactate 2.8 mmol/L (mildly elevated)
Chest X-ray: Right lower lobe infiltrate with patchy consolidation, no effusion, subtle infiltrate left base
Blood cultures: Drawn, pending

A – Assessment:

81-year-old female with aspiration pneumonia, likely following witnessed aspiration event during meal yesterday. Clinical presentation consistent with aspiration: nursing home resident with known dysphagia, dementia, history of CVA, witnessed choking episode, and right lower lobe predominant infiltrate (most common site for aspiration). Altered mental status likely multifactorial from infection, dehydration, and baseline dementia. Patient meets SIRS criteria with elevated WBC, tachycardia, tachypnea, and fever. Acute kidney injury likely pre-renal from dehydration. Requires hospital admission for IV antibiotics and supportive care. CURB-65 score: 4 (high risk - age greater than 65, confusion, elevated BUN, tachypnea). Goals of care discussion needed with family given advanced age, multiple comorbidities, and poor functional status.

P – Plan:

Admit to medical floor with telemetry monitoring. Initiated aspiration pneumonia coverage: ampicillin-sulbactam 3g IV every 6 hours (covers oral anaerobes and gram-negatives). NPO status until swallow evaluation completed. IV fluid resuscitation with normal saline bolus 500mL followed by maintenance fluids for dehydration and AKI. Supplemental oxygen via nasal cannula to maintain O2 sat greater than 90%. Head of bed elevated 30-45 degrees at all times. Consulted speech therapy for bedside swallow evaluation tomorrow AM to assess aspiration risk before resuming any oral intake. May require video swallow study if bedside evaluation concerning. Continue home medications via IV or alternative routes where possible. Monitor mental status closely - if continued decline, consider head CT to rule out new CVA. Contacted family to discuss current condition, treatment plan, and goals of care given overall decline and recurrent aspiration risk. Family requesting full treatment at this time. Follow-up labs in AM including repeat BMP to assess kidney function response to hydration. Daily chest X-rays to monitor progression. PT/OT consult for mobility and safe feeding positioning recommendations. Social work to coordinate with nursing home regarding discharge planning and need for enhanced aspiration precautions. Will reassess need for upgraded level of care if respiratory status worsens.

---

Key Elements Insurance Companies Look for in Pneumonia Documentation

When you're documenting pneumonia cases, insurance reviewers specifically want to see:

Severity Assessment

Use CURB-65 or PSI scoring to justify admission vs. outpatient treatment. Document the score explicitly in your assessment.

Antibiotic Justification

Explain your antibiotic choice based on likely organisms, local resistance patterns, patient allergies, and CAP vs. HAP classification.

Oxygenation Status

Always document O2 saturation on room air first, then on supplemental oxygen if needed. This justifies oxygen therapy orders.

Imaging Interpretation

Don't just say "infiltrate present" - specify location, size, any complications like effusion or cavitation.

Risk Factors

Document factors that influenced your management: immunocompromised status, recent antibiotics, COPD, heart failure, nursing home residence.

Follow-Up Plan

Clear documentation of when you'll reassess response to treatment and what triggers would prompt escalation of care.

Conclusion

And if all of these feel like work…

Head over to soapnotes.doctor.