SOAP Note Example for an Asthma Exacerbation (Sample)

By Raj Lakhani, Founder · Updated June 2026

A strong SOAP note example for an asthma exacerbation documents the trigger and symptom timeline (Subjective), measurable severity such as peak flow, SpO2, respiratory rate, and accessory muscle use (Objective), a clear severity grade with the working diagnosis (Assessment), and the bronchodilator, steroid, and follow-up plan you acted on (Plan). The sample note below is realistic and ready to adapt to your own encounters.

What belongs in the Subjective section of an asthma exacerbation note?

The Subjective section captures the patient's story in their words and the data only they can give you. For an exacerbation, anchor it to onset, trigger, and how the current episode compares to baseline control.

Symptom timeline: when wheeze, cough, or dyspnea started and whether it is worsening
Likely trigger: URI, allergen, exercise, smoke, cold air, or missed controller doses
Rescue inhaler use: puffs in the last 24 hours and whether it is helping
Baseline control: usual peak flow, recent ED visits, prior intubations, and current controller regimen
Red flags by history: speaking in words not sentences, chest tightness at rest, nocturnal waking

What objective findings should the note capture in an asthma exacerbation?

Objective is where severity becomes defensible. Record numbers, not adjectives, so another clinician can grade the episode the same way you did.

Vitals: SpO2 on room air, respiratory rate, heart rate, temperature
Peak expiratory flow (PEF) as an absolute value and percent of personal best or predicted
Work of breathing: accessory muscle use, retractions, ability to speak in full sentences
Lung exam: air movement, wheeze (inspiratory vs expiratory), prolonged expiratory phase, or the ominous silent chest
Mental status and response to initial bronchodilator therapy

How do you grade asthma exacerbation severity in the Assessment?

The Assessment names the working diagnosis and assigns a severity tier, because that tier drives disposition and the steroid decision. Tie the grade directly to the objective data you charted.

Mild to moderate: PEF roughly 50 to 79 percent of best, SpO2 at or above 94 percent, speaking in sentences
Severe: PEF under 50 percent, SpO2 below 94 percent, accessory muscle use, speaking in short phrases
Life-threatening: silent chest, drowsiness, exhaustion, or a falling respiratory rate suggesting fatigue

State your differential too. Rule-outs worth a line include pneumonia, COPD overlap, heart failure, anaphylaxis, and pulmonary embolism when the picture is atypical.

What is a complete SOAP note example for an asthma exacerbation?

Here is a concrete sample for a moderate exacerbation managed in clinic. Adjust doses and disposition to your patient and local protocol.

S: 34-year-old female with known mild persistent asthma presents with 2 days of
worsening wheeze, cough, and chest tightness after a head cold. Using albuterol
MDI every 3-4 hours with partial relief (~10 puffs/24h). Daily fluticasone, admits
missing doses for the past week. No fever, no chest pain, no leg swelling. Speaking
in full sentences. Last ED visit 2 years ago; never intubated.

O: T 37.1 C, HR 104, RR 22, BP 128/78, SpO2 93% on room air.
   PEF 280 L/min (personal best 420, ~67% predicted).
   General: mild distress, speaking in sentences, no cyanosis.
   Lungs: bilateral expiratory wheeze, prolonged expiratory phase, good air entry,
   no focal crackles. Mild use of accessory muscles. No tripod positioning.
   Cardiac: tachycardic, regular, no murmur.

A: Moderate acute asthma exacerbation, likely viral-triggered, on a background of
   suboptimal controller adherence. PEF 67% best, SpO2 93%. No features of
   life-threatening attack. Differential considered: pneumonia (no fever/focal
   findings), CHF (no edema), PE (low pretest probability).

P: - Albuterol 2.5 mg neb x3 over the first hour (or 4-8 MDI puffs via spacer q20min)
   - Ipratropium added to first nebs given moderate severity
   - Prednisone 40 mg PO daily x5 days, first dose given in clinic
   - Reassess PEF and SpO2 after treatment; target PEF >320 and SpO2 >=94% before
     discharge
   - Reinforce daily fluticasone; review inhaler technique and spacer use
   - Provide written asthma action plan; return precautions: worsening dyspnea,
     speaking in words, SpO2 drop -> ED now
   - Follow up in 3-5 days; consider stepping up controller therapy

How should the Plan document treatment and follow-up?

The Plan should read like an action log, not a wish list. Note what you gave, the response you are watching for, and the safety net you built.

Acute meds with dose, route, and frequency: short-acting beta-agonist, ipratropium when moderate or severe, systemic steroids
Objective reassessment: repeat PEF and SpO2 after treatment with explicit discharge thresholds
Disposition logic: discharge, observation, or ED transfer, and why
Controller optimization and inhaler technique check
Written asthma action plan, return precautions, and follow-up interval

FAQ

Do you always need a peak flow in an asthma exacerbation note?

A peak flow gives an objective severity anchor and makes your grade defensible, so include it whenever the patient can perform the maneuver. If they are too dyspneic, too young, or unable to cooperate, document that and lean on SpO2, respiratory rate, work of breathing, and speech.

How long does a good asthma SOAP note take to write?

With a clear template the note itself takes only a few minutes once the visit is done. Many clinicians shave most of that time with an AI scribe like Doctor Notes, which drafts the structured SOAP note from the visit so you mainly review the severity grade, meds, and disposition.

What is the most commonly missed element in these notes?

The reassessment after treatment is the line most often left out, yet it is what justifies discharge versus escalation. Always chart a post-treatment PEF or SpO2 and the explicit thresholds you used to decide disposition.