Pulmonology SOAP Note

Date: [Date]

Patient: [Patient name / ID]

Provider: [Provider name, credentials]

Visit Type: [follow-up / interval check / other: ____]

Location: [Clinic location]

Subjective

Chief Complaint: [Chief complaint in patient's words] (If scheduled follow-up without new complaint, document as "Interval follow-up for [condition].")

Interval History: [Events since last pulmonology visit including exacerbations, hospitalizations, ED visits, steroid/antibiotic courses, and changes in baseline symptoms or functional status] (If none, explicitly state "No interval exacerbations or hospitalizations.")

History of Present Illness: [Narrative synthesis of current respiratory symptoms and trajectory, addressing onset/course, triggers, functional impact, and comparison to baseline; include standardized scores or functional measures when used]

Respiratory Regimen: [Current controller and reliever medications with device type, dose/frequency, adherence, and side effects] — Inhaler technique: [assessed and correct / assessed with errors corrected / not assessed] (Include home oxygen details if applicable: flow rates at rest/exertion/sleep, delivery device, adherence. Include PAP therapy details if applicable: modality, tolerance, whether objective adherence data reviewed. For oxygen or PAP patients, if settings not assessed, state "Not assessed today.")

Exposures/Risk Factors: [Tobacco status with pack-years and quit date; vaping; occupational or environmental exposures relevant to management]

Relevant Comorbidities: [Conditions affecting respiratory assessment and their relationship to current symptoms, e.g., GERD, heart failure, OSA, obesity]

Objective

Vitals: BP [___/___], HR [___], RR [___], Temp [___], SpO2 [___]% on [room air / ___ L/min O2 via ___], Weight/BMI [___] (SpO2 must specify room air or oxygen with flow rate and device.)

Exam: [General appearance and work of breathing; lung sounds including breath sounds, wheeze, crackles, symmetry; pertinent cardiovascular or other system findings] (Document only what was actually examined.)

Data Review: [Relevant diagnostics reviewed at this visit] (Use format: Test (date): findings → interpretation → trend. Include as applicable: PFTs with key values, interpretation, bronchodilator response, quality/acceptability, and comparison to prior; imaging with key pulmonary findings; pulmonary-relevant labs such as eosinophils, IgE, alpha-1 antitrypsin, sputum cultures; PAP download with usage, residual AHI, and leak summary.)

Medications: Medication list reviewed and reconciled: [yes / no]. [Respiratory medications with device/dose/frequency; note discrepancies addressed]

Assessment

[One- to two-sentence clinical summary linking subjective trajectory with objective findings]

[Problem 1]: [Diagnosis with phenotype if known]

Status: [stable / improving / worsening], [controlled / uncontrolled]. Supporting evidence: [Key data points with dates]. (If diagnosis uncertain, state differential with reasoning.)

[Problem 2]: [Diagnosis with phenotype]

(Include additional problems only if addressed at this visit.)

Plan

[Problem 1]

Diagnostics: [Tests ordered with rationale]

Medications: [Changes with device and dosing instructions]

Non-pharmacologic: [Pulmonary rehab / airway clearance / smoking cessation / other as applicable]

Education: [Inhaler technique corrections / action plan updates / oxygen safety counseling as applicable]

Monitoring: [Home metrics, thresholds, red-flag symptoms]

Follow-up: [Interval and pre-visit data to obtain]

(For asthma: document action plan status. For oxygen changes: document qualifying oxygenation data, prescribed flow rates by condition, device, and safety counseling provided. For immunization-eligible patients: note vaccination review.)

[Problem 2]

(Repeat structure for each additional problem addressed.)

(Omit elements not assessed unless high-safety items such as oxygen or PAP settings, in which case state "Not assessed today." Do not assume normal findings unless explicitly elicited. If clinically important information is unknown, document "Unknown" and plan to obtain.)