How to Write Perfect SOAP Notes for URI Cases (With Examples)

If you’ve ever sat staring at a blank page, trying to piece together a SOAP note for a patient with the sniffles, you’re not alone.
URI cases may be the bread and butter of primary care, but writing them up clearly can still feel tricky.

As the founder of SOAP Notes Doctor, I’ve seen how much time and stress goes into getting these notes right, and I’m here to make it easier.

In this article, we’ll walk through what makes a good SOAP note for an upper respiratory infection, break it down step by step, and give you practical tips you can use right away.

SOAP Notes in a Jiffy

SOAP notes are the backbone of clinical documentation.
The acronym stands for Subjective, Objective, Assessment, and Plan — a simple, structured way to capture patient encounters.

It’s the format you’ll find in hospitals, clinics, and even student rotations because it keeps notes concise, consistent, and easy to follow.

The idea behind SOAP notes was first introduced in the late 1960s by Dr. Lawrence Weed, who wanted a systematic way for clinicians to organize information and make decisions.
His work led to what we now call the problem-oriented medical record (POMR), and SOAP notes became one of its most practical tools.

Fast forward to today, and SOAP notes remain a universal language in healthcare.
Whether you’re a medical student, nurse practitioner, or seasoned physician, you’re using the same framework to tell a patient’s story.

That’s what makes them powerful and also why getting comfortable with them early is so important.

How to Approach SOAP Notes for URI

Upper respiratory infections (URIs) are some of the most common cases you’ll see in primary care.

But common doesn’t mean careless.
A well-written SOAP note for URI should tell the story of what happened in the room and guide the next provider on what to do next.

If you can learn to write a clean, clear URI note, you can write just about anything else.

Subjective (S): Get the Patient’s Story, Not Just Their Symptoms

The subjective section should capture what the patient tells you.

For URI, this usually means cough, congestion, sore throat, fever, or general malaise.

Instead of just writing “cough x 3 days,” expand it to give context.

I recommend using a focused history framework like OLDCARTS (Onset, Location, Duration, Character, Aggravating/alleviating factors, Radiation, Timing, Severity).
But don’t overcomplicate it — for URI, duration, severity, and associated symptoms (like fever, shortness of breath, ear pain) matter the most.

👉 Pro tip: Always document relevant negatives.
For example, if the patient denies chest pain, shortness of breath, or high fever — write that down.
It helps differentiate URI from pneumonia, bronchitis, or strep.

Think of it this way: if you handed this note to a colleague, could they picture the patient encounter?
If not, expand it a bit more.

Objective (O): Be Precise and Focused

This section is what you observed:
Vitals, physical exam, and any in-office tests (like rapid strep).

For URI, vitals are gold.
A temperature of 101°F means something very different from 99°F.
Always include respiratory rate — it shows you considered respiratory distress.
On physical exam, document what you actually examined.
For URI, this often includes pharyngeal erythema, nasal congestion, lung sounds, ear exam, and lymph nodes.

⚠️ Avoid over-documenting. Writing “lungs clear” when you didn’t listen to all fields can hurt you later.

My personal rule: write what you actually saw, not what you assume is normal.

Assessment (A): Keep It Simple but Thoughtful

For a straightforward viral URI, the assessment might be as simple as:

“Likely viral upper respiratory infection.”

But I recommend adding a short reasoning line:

“No evidence of bacterial infection (afebrile, lungs clear, no tonsillar exudate).”

This shows you considered differentials and ruled out more serious causes like pneumonia or strep.

You can also list differentials briefly in order of likelihood, for example:

Viral URI – most likely
Allergic rhinitis – possible given clear rhinorrhea and no fever
Bacterial sinusitis – unlikely at this time (symptoms less than days, no purulent discharge)

Plan (P): Give Clear Next Steps

The plan should outline what happens next.

Be explicit:

Supportive care: fluids, rest, OTC analgesics
Symptom relief: saline spray, honey, warm gargles
Warning signs: worsening fever, difficulty breathing, chest pain
Follow-up: when to return if no improvement or symptoms worsen

If you prescribe meds or order tests, include dose, duration, and instructions.

👉 Write the plan as if another provider had to take over tomorrow. Would they know exactly what to do?

If yes, you’ve written a good plan.

Sample SOAP Notes for URI

Example 1: Classic Viral URI

S – Subjective
Patient is a 27-year-old female presenting with nasal congestion, sore throat, and mild cough for the past 3 days. Reports low-grade fever at home (max 100.1°F). Denies chest pain, shortness of breath, wheezing, or ear pain. No recent sick contacts identified, though she works in an office with multiple colleagues who have had colds. Past medical history unremarkable. No allergies. No current medications.

O – Objective

Vitals: T 99.8°F, HR 82, BP 118/76, RR 16, O2 sat 98% RA
General: Alert, not in distress
HEENT: Mild pharyngeal erythema without exudate, nasal mucosa congested with clear rhinorrhea, no tonsillar swelling, tympanic membranes clear
Neck: Mild anterior cervical lymphadenopathy, non-tender
Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi
Cardiovascular: Regular rate and rhythm, no murmurs

A – Assessment
Likely viral upper respiratory infection. Findings do not suggest bacterial pharyngitis (no exudate, afebrile, no tender cervical nodes) or pneumonia (lungs clear, no hypoxia).

P – Plan

Supportive care: fluids, rest, acetaminophen/ibuprofen as needed
Symptom relief: saline spray, warm gargles, honey for cough
Education: natural course, usually resolves in 7–10 days
Red flags: return for fever >101.5°F, chest pain, difficulty breathing, or persistence >10 days
Follow-up: return if not improving in 1 week

Example 2: URI with Concern for Bacterial Pharyngitis

S – Subjective
Patient is a 16-year-old male presenting with sore throat, fever, and difficulty swallowing for 2 days. Reports fatigue and mild headache. No cough or rhinorrhea. History of recurrent strep infections. No drug allergies.