SOAP note example: asthma

Asthma notes are judged on two things: can the reader tell how well controlled the patient is, and can they see what the patient was told to do when it gets worse. The invented notes below show a control review and an acute visit. After them is a section-by-section guide, the gaps that come up most, and the J45 code family.

Example: asthma control review

S: 27-year-old woman with asthma since childhood. Uses salbutamol inhaler about 3 times a week for wheeze and chest tightness, mostly with exercise and cold air. Woken by cough once in the last month. No oral steroid courses in the past year. Not on a preventer. Cat at home. Non-smoker, no vaping. No heartburn. Works in an office.
O: Speaking full sentences. RR 14, SpO2 98% on air. Chest clear, no wheeze. Peak flow 390 L/min, personal best 440. Inhaler technique: metered-dose inhaler without spacer, fast inhalation and no breath hold.
A: Asthma, partly controlled on reliever alone. Symptoms more than twice a week. No recent exacerbation.
P: 1. Start budesonide-formoterol 200/6 one inhalation as needed for symptoms, replacing salbutamol. Maximum daily inhalations explained.
2. Dry-powder inhaler technique taught and checked back.
3. Written asthma action plan given, with peak flow zones based on 440.
4. Annual flu vaccine offered.
5. Review in 6 weeks.
6. Urgent care if reliever is not helping, she cannot speak in sentences, or peak flow falls below 220.

Section by section for asthma

1. Subjective. Daytime symptoms and reliever use per week, night waking, activity limitation, exacerbations and oral steroid courses in the last year, emergency visits or admissions, triggers, smoking and vaping, adherence to any preventer, and comorbid rhinitis or reflux.
2. Objective. Ability to speak in sentences, respiratory rate, SpO2, heart rate in acute visits, chest findings, peak flow against personal best or predicted, and an observed inhaler technique check. Spirometry or FeNO results if done.
3. Assessment. Control level (well, partly or poorly controlled), future exacerbation risk, and in acute visits the severity of the attack.
4. Plan. Each inhaler with dose and when to use it, technique teaching, the written action plan, trigger advice, vaccines, review date, and explicit instructions for when to seek urgent help.

A useful habit is to write reliever use as a number per week. "Uses inhaler sometimes" cannot be compared at the next visit; "3 times a week" can.

Example: mild to moderate exacerbation

S: 33-year-old man with asthma, 2 days of wheeze after a cold. Using reliever every 3 to 4 hours with partial relief. On budesonide-formoterol as needed. No previous intensive care admission.
O: Speaking in sentences. RR 22, pulse 104, SpO2 95%. Scattered expiratory wheeze. Peak flow 310 L/min, 62% of best (500). After 4 puffs salbutamol via spacer: peak flow 380 (76%), wheeze reduced.
A: Moderate asthma exacerbation, responding to bronchodilator.
P: Prednisolone 40 mg once daily for 5 days. Reliever as per action plan. Check technique. Review in 48 hours. Emergency department if worse, peak flow below 250, or reliever lasting under 4 hours.

Where asthma notes fall short

• No count of reliever use or night waking, so control cannot be graded.
• Peak flow written without the personal best or predicted value.
• Inhaler technique assumed rather than observed.
• Action plan mentioned but not whether a written copy was given.
• Oral steroid courses in the last year not asked, which hides exacerbation risk.
• In acute visits, no post-treatment observations before discharge.

ICD-10 codes in the asthma family

These are ICD-10-CM subcodes. The base ICD-10 list uses J45.0 to J45.9 and J46 for acute severe asthma.

Letting ClearPass draft the asthma note

During the visit, Transcribe listens once the patient has agreed. The SOAP note that comes back puts reliever use and night symptoms in S, peak flow and the technique check in O, the control level in A, and the inhaler plan and action-plan advice in P. Concise suits a quick review; Detailed keeps every trigger and every number.

Peak flows and oxygen saturations are marked by the numbers check if they were never said in the transcript. One click gives patient instructions you can hand over with the action plan, another gives a referral letter if you want a respiratory opinion, and ICD-10 codes are one click too. You review the draft before it is used.

What ClearPass does not do

• It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
• It is not a medical device and does not make clinical decisions. It is a documentation aid.
• It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

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