SOAP Notes for Asthma (with Examples)

Asthma is a long-term breathing condition that affects the airways of the lungs. People with asthma have sensitive airways that can swell, tighten, and produce extra mucus. This makes breathing hard, especially during attacks. Because asthma can change from day to day, clear and detailed documentation is very important. SOAP notes help clinicians record symptoms, exam findings, decisions, and treatment plans in a clear and organized way.

SOAP notes are used in clinics, hospitals, urgent care, and emergency settings. They help track asthma control, identify triggers, adjust medications, and prevent future attacks. For students and new clinicians, asthma SOAP notes also help build strong clinical thinking. For experienced clinicians, they improve care quality and protect legal documentation. This guide shows how to write good SOAP notes for asthma, with examples for common situations.

What Are SOAP Notes?

SOAP notes are a structured way to write medical notes. The word SOAP stands for Subjective, Objective, Assessment, and Plan. Each section has a clear purpose and should not mix with the others. This structure helps keep notes easy to read and understand.

The Subjective section includes what the patient says. The Objective section includes what the clinician sees, hears, or measures. The Assessment section explains the clinical judgment. The Plan section lists what will be done next. When used correctly, SOAP notes give a full picture of the patient’s asthma condition.

For asthma, SOAP notes are especially useful because symptoms can change quickly. Patients may feel better one day and worse the next. Clear notes help track these changes over time and support better treatment decisions.

Why SOAP Notes Are Important in Asthma Care

Asthma is not the same for every patient. Some patients have mild symptoms once in a while, while others have frequent attacks. SOAP notes help capture these differences in detail. They allow clinicians to track symptom frequency, triggers, medication use, and response to treatment.

Good asthma SOAP notes also help prevent errors. Missing details like inhaler use, nighttime symptoms, or peak flow readings can lead to poor asthma control. Clear notes reduce confusion between healthcare providers and improve teamwork.

From a legal and safety point of view, asthma notes are important because asthma attacks can be serious. Proper documentation shows that symptoms were assessed, risks were considered, and correct treatment steps were taken.

Structure of SOAP Notes for Asthma

When writing asthma SOAP notes, each section should stay focused on its role. Mixing information between sections can reduce clarity and lower note quality. Below is a detailed explanation of each SOAP section, with asthma-specific guidance.

Subjective

The Subjective section is where the patient’s voice is written. It includes symptoms, concerns, and history as reported by the patient or caregiver. Nothing in this section should be based on tests or measurements.

For asthma, the Subjective section is very important because many key details come directly from the patient. Breathing problems are often described in personal terms, such as chest tightness or feeling short of breath.

What to Include in Subjective for Asthma

Patients with asthma may report many symptoms. These can include shortness of breath, wheezing, coughing, and chest tightness. Some patients describe trouble breathing at night or early in the morning. Others may say their symptoms worsen with exercise, cold air, smoke, or allergens.

Medication history is also important. Ask if the patient uses a rescue inhaler and how often. Frequent use can mean poor asthma control. Ask if the patient uses a daily controller inhaler and if they miss doses. Poor adherence is a common cause of asthma flare-ups.

Triggers should always be documented. Common triggers include dust, pollen, pets, mold, smoke, cold weather, infections, and stress. For children, school activities and play may also trigger symptoms.

Objective

The Objective section includes findings that the clinician can observe or measure. This section should be factual and free from opinions. It often includes vital signs, physical exam results, and test findings.

For asthma, objective data helps confirm symptom severity and guides treatment decisions. It also helps compare current status with past visits.

What to Include in Objective for Asthma

Vital signs are very important. Record respiratory rate, heart rate, blood pressure, temperature, and oxygen saturation. Low oxygen levels can signal a serious asthma attack.

The lung exam should be clearly documented. Note wheezing, decreased breath sounds, prolonged exhalation, or use of accessory muscles. Also document if the patient is speaking in full sentences or struggling to talk.

If available, include peak flow readings or spirometry results. These numbers give objective information about airflow limitation. Compare them to the patient’s personal best if known.

Assessment

The Assessment section explains the clinician’s medical judgment. It combines subjective and objective information to describe the patient’s condition. This is where the asthma diagnosis and severity are stated.

The Assessment should be clear and specific. Avoid vague terms like “doing okay.” Instead, describe asthma control and current status.

What to Include in Assessment for Asthma

State the asthma type and severity, such as mild intermittent asthma or moderate persistent asthma. If the patient is having an attack, note whether it is mild, moderate, or severe.

Include any contributing factors, such as poor inhaler use, recent infection, or allergen exposure. If asthma is not well controlled, clearly state this.

If other conditions are involved, such as allergic rhinitis or respiratory infection, include them as secondary assessments.

Plan

The Plan section lists what will be done next. This includes medications, tests, education, and follow-up. The plan should be clear and actionable.

For asthma, the Plan often focuses on symptom relief, airway control, and prevention of future attacks.

What to Include in Plan for Asthma

Medications should be listed with name, dose, route, and frequency. This includes rescue inhalers, controller inhalers, steroids, or nebulizer treatments.

Patient education is very important. Include inhaler technique review, trigger avoidance advice, and action plan instructions. Good education improves asthma control.

Follow-up plans should be specific. Note when the patient should return and what symptoms require urgent care.

Asthma SOAP Note Examples

Acute Asthma Exacerbation (Adult)

Subjective (S)

The patient is a 34-year-old adult with a known history of asthma who presents with worsening shortness of breath for the past 8 hours. The patient reports tightness in the chest, wheezing, and continuous coughing. Breathing feels fast and shallow, and the patient says it is difficult to take a deep breath. Symptoms started suddenly after exposure to cold air while outdoors.

The patient reports using a rescue albuterol inhaler multiple times today, approximately 6–8 puffs, with only short and mild relief. The patient denies fever, chills, chest pain, or recent illness. No nausea or vomiting reported. Sleep was disturbed due to breathing difficulty.

Past history includes asthma since childhood with previous emergency visits for asthma flares. The patient reports inconsistent use of the daily controller inhaler. No known drug allergies. No smoking history.

Objective (O)

• Respiratory rate: 26 breaths per minute
• Heart rate: 108 beats per minute
• Blood pressure: 138/86 mmHg
• Temperature: 98.4°F (36.9°C)
• Oxygen saturation: 91% on room air

The patient appears anxious and is sitting upright to breathe. Use of accessory muscles is noted. The patient is speaking in short phrases rather than full sentences. Lung examination reveals loud, diffuse expiratory wheezing in all lung fields with prolonged expiration. Breath sounds are decreased at the bases.

Peak expiratory flow reading is 250 L/min, which is approximately 55% of the patient’s personal best. No cyanosis noted. No signs of infection on exam.

Assessment (A)

Acute asthma exacerbation, moderate in severity. Symptoms are poorly controlled at home with frequent rescue inhaler use and reduced peak flow. Likely triggered by cold air exposure and poor adherence to controller medication. No evidence of pneumonia or other acute infection at this time.

Plan (P)

• Administer nebulized short-acting bronchodilator treatments every 20 minutes for three doses.
• Start systemic corticosteroids to reduce airway inflammation.
• Provide supplemental oxygen to maintain oxygen saturation above 94%.
• Monitor respiratory status, peak flow, and oxygen levels closely.
• Reassess lung sounds and breathing after treatments.

Education:

• Review correct inhaler technique.
• Stress the importance of daily controller inhaler use.
• Educate the patient on early warning signs of asthma worsening.
• Review and update the written asthma action plan.

Disposition and Follow-Up:

• Discharge when symptoms improve, wheezing decreases, and peak flow improves to above 70% of personal best.
• Advise follow-up with primary care or pulmonology within 2–3 days.
• Instruct the patient to seek emergency care if breathing worsens, rescue inhaler provides no relief, or speech becomes difficult.

Chronic Asthma Follow-Up Visit (Adult)

Subjective (S)

The patient is a 42-year-old adult with a known history of asthma who presents for a routine follow-up visit. The patient reports ongoing breathing symptoms over the past several months. Shortness of breath occurs about two to three times per week, usually with activity such as climbing stairs or brisk walking. The patient also reports mild wheezing during these episodes.

Nighttime symptoms are present about once per week, mainly as coughing that wakes the patient from sleep. The patient uses a rescue albuterol inhaler approximately three times per week. Relief is usually quick after inhaler use. The patient denies recent emergency visits or hospitalizations for asthma.

The patient admits missing doses of the daily controller inhaler several times per week, mainly due to forgetfulness. Known triggers include dust, seasonal pollen, and cold air. The patient denies chest pain, fever, recent infections, or weight loss. No smoking history. No new medications started since the last visit.

Objective (O)

• Blood pressure: 124/78 mmHg
• Heart rate: 76 beats per minute
• Respiratory rate: 18 breaths per minute
• Temperature: 98.2°F (36.8°C)
• Oxygen saturation: 98% on room air

The patient appears comfortable at rest and is speaking in full sentences. No use of accessory muscles noted. Lung examination reveals mild end-expiratory wheezing bilaterally, more noticeable with forced exhalation. No crackles or rhonchi heard.

Peak expiratory flow is 420 L/min, which is approximately 80% of predicted for age, sex, and height. No cyanosis or clubbing noted. Nasal mucosa appears mildly swollen, suggesting allergic symptoms.

Assessment (A)

Moderate persistent asthma, partially controlled. Ongoing daytime and nighttime symptoms with increased rescue inhaler use. Poor adherence to controller medication is likely contributing to incomplete asthma control. Possible allergic trigger involvement.

Plan (P)

• Continue inhaled corticosteroid as the primary controller medication.
• Reinforce daily use of the controller inhaler and explain its role in preventing symptoms.
• Continue short-acting bronchodilator as needed for acute symptoms.
• Consider step-up therapy if symptoms do not improve with better adherence.

Education:

• Review proper inhaler technique to ensure effective medication delivery.
• Discuss strategies to improve medication adherence, such as daily reminders.
• Counsel on trigger avoidance, including dust control and allergen reduction at home.
• Review asthma action plan and symptom monitoring.

Follow-Up:

• Schedule follow-up visit in 4–6 weeks to reassess symptom control and inhaler use.
• Advise the patient to return sooner if symptoms worsen, nighttime awakenings increase, or rescue inhaler use becomes more frequent.

Pediatric Asthma Visit

Subjective (S)

The patient is a 7-year-old child with a known history of asthma who presents with a parent for a routine asthma follow-up visit. The parent reports that the child has been coughing almost every night for the past two weeks. The cough is dry and often wakes the child from sleep. The parent also notices wheezing during playtime and running, especially during outdoor activities.

The child has been using a rescue inhaler nearly every day, sometimes more than once per day. The parent reports that symptoms improve after inhaler use but return later in the day. There have been no recent emergency room visits or hospital admissions. No fever, sore throat, or recent cold symptoms are reported.

Known triggers include dust, cold air, and physical activity. The child uses a spacer with the inhaler but sometimes resists using it. The parent admits that the daily controller inhaler is missed several times per week due to school schedules and forgetfulness. No known drug allergies. Immunizations are up to date.

Objective (O)

• Respiratory rate: 22 breaths per minute
• Heart rate: 96 beats per minute
• Blood pressure: 98/62 mmHg
• Temperature: 98.6°F (37.0°C)
• Oxygen saturation: 96% on room air

The child appears alert and playful but becomes mildly short of breath with activity. No nasal flaring or use of accessory muscles at rest. Lung examination reveals mild bilateral expiratory wheezing, more noticeable after exertion. Breath sounds are equal bilaterally.

Peak flow testing was attempted but was inconsistent due to age and cooperation. No cyanosis or clubbing noted. Nasal mucosa appears mildly congested, suggesting possible allergic rhinitis. Growth parameters are appropriate for age.

Assessment (A)

Pediatric asthma, poorly controlled. Frequent nighttime coughing and daily rescue inhaler use indicate inadequate asthma control. Poor adherence to controller medication and exposure to known triggers are likely contributing factors.

Plan (P)

• Adjust daily controller inhaler dose to improve symptom control.
• Continue short-acting bronchodilator as a rescue medication as needed.
• Encourage consistent use of spacer with all inhaler treatments.

Education:

• Teach the parent and child correct inhaler and spacer technique.
• Explain the importance of daily controller medication, even when the child feels well.
• Discuss trigger avoidance strategies, including dust reduction and cold air protection.
• Provide a written pediatric asthma action plan with clear steps for symptom worsening.

Follow-Up:

• Schedule follow-up visit in 2–3 weeks to reassess symptom control.
• Advise the parent to seek urgent care if the child develops severe breathing difficulty, persistent wheezing, or poor response to rescue inhaler.

Exercise-Induced Asthma (Exercise-Induced Bronchoconstriction)

Subjective (S)

The patient is a 19-year-old individual who presents with breathing problems that occur only during physical activity. The patient reports shortness of breath, chest tightness, and wheezing that begin about 5–10 minutes after starting exercise, especially running or playing sports. Symptoms usually improve within 15–20 minutes after stopping activity.

The patient denies breathing problems at rest, during sleep, or with daily activities. No nighttime coughing is reported. The patient uses a rescue albuterol inhaler before exercise, which helps prevent symptoms most of the time. If the inhaler is not used before activity, symptoms are more noticeable.

The patient denies recent illness, fever, chest pain, or dizziness. No history of smoking or vaping. No known allergies. Family history is positive for asthma. The patient has no prior hospitalizations or emergency visits for breathing problems.

Objective (O)

• Blood pressure: 118/74 mmHg
• Heart rate: 72 beats per minute at rest
• Respiratory rate: 16 breaths per minute
• Temperature: 98.1°F (36.7°C)
• Oxygen saturation: 99% on room air

The patient appears comfortable and is breathing normally at rest. No use of accessory muscles. Lung examination reveals clear breath sounds with no wheezing at rest. No prolonged expiration noted.

Baseline peak expiratory flow is within normal range for age, sex, and height. No cyanosis or clubbing observed. Cardiovascular and upper airway exams are unremarkable.

Assessment (A)

Exercise-induced asthma (exercise-induced bronchoconstriction). Symptoms occur only with physical exertion and resolve with rest or pre-exercise bronchodilator use. No evidence of persistent or uncontrolled chronic asthma at this time.

Plan (P)

• Continue short-acting bronchodilator (albuterol) 10–15 minutes before exercise.
• Educate the patient on proper inhaler technique to ensure full medication delivery.
• Encourage gradual warm-up before exercise and cool-down after activity.
• Advise avoidance of cold, dry air during exercise when possible or use a face covering.

Education:

• Explain that exercise-induced asthma does not mean the patient should avoid physical activity.
• Discuss recognizing early symptoms and stopping activity if breathing becomes difficult.
• Review signs that may suggest progression to chronic asthma, such as nighttime symptoms or symptoms at rest.

Follow-Up:

• Follow up in 6–8 weeks or sooner if symptoms worsen or occur outside of exercise.
• Consider further testing or controller therapy if exercise symptoms become more frequent or severe despite pre-exercise treatment.

Common Mistakes in Asthma SOAP Notes

1. Notes are too brief and lack detail: Many asthma SOAP notes are written very quickly and miss important information. Short notes often leave out symptom patterns, triggers, or how asthma affects daily life. This makes it harder to judge asthma control over time.
2. Not recording rescue inhaler use clearly: A common mistake is failing to document how often the patient uses a rescue inhaler. Frequent use is a strong sign of poor asthma control. Without this detail, the severity of asthma may be underestimated.
3. Mixing opinions into the Objective section: Writing statements like “patient looks anxious” without clear physical signs is inappropriate for the Objective section. This section should only include measurable or observable findings, such as wheezing, oxygen levels, or respiratory rate.
4. Unclear or vague assessment statements: Some notes use general phrases like “asthma stable” or “doing better” without explaining why. The Assessment should clearly state asthma severity, level of control, and any contributing factors.
5. Missing patient education and follow-up plans: Asthma management requires ongoing education and monitoring. Failing to document inhaler technique review, trigger avoidance advice, or follow-up timing weakens the note and the overall care plan.
6. Poor separation of SOAP sections: Another common issue is placing plan details in the Assessment or subjective complaints in the Objective section. Each part of the SOAP note should stay in its proper place to keep documentation clear and organized.

Tips for Writing Better Asthma SOAP Notes

• Always write symptoms clearly and in detail. Include frequency, severity, and triggers. This helps track asthma control over time.
• Use exact numbers when possible, such as oxygen levels and peak flow readings. These details improve accuracy and clarity.
• Focus on function, not just symptoms. Explain how asthma affects daily activities, sleep, and exercise.

Final Thoughts

SOAP notes play an important role in asthma care because asthma symptoms can change quickly. Clear and well-written notes help clinicians understand what the patient is experiencing, how severe the symptoms are, and what treatment steps are needed next. When details are recorded properly, it becomes easier to monitor progress, adjust medications, and reduce the risk of serious asthma attacks.

Keeping the language simple and the structure clear makes SOAP notes easier to read and share with other healthcare team members. By using the examples and tips in this guide, you can feel more confident writing asthma SOAP notes that support safe, consistent, and high-quality care—whether you are still learning or already working in clinical practice.