SOAP note example: COPD
Chronic obstructive pulmonary disease reviews mix long-term numbers (spirometry, exacerbations per year, smoking pack-years) with how the patient is managing this month. A good note lets the next clinician decide on inhalers, rehabilitation and vaccines without repeating the history. Here is an invented stable review, an exacerbation note, and a guide to each section.
Example: stable COPD review
S: 66-year-old man with COPD diagnosed 3 years ago. Ex-smoker, stopped 2 years ago, 40 pack-years. Breathless walking up one flight of stairs, stops after 100 m on the flat (mMRC 2). Morning cough with white sputum. One exacerbation in the last year treated at home with prednisolone and antibiotics; no admissions. On tiotropium 2.5 micrograms, 2 inhalations once daily, and salbutamol as needed about twice a day. No ankle swelling. Lives with wife, independent. O: RR 18, SpO2 94% on air, pulse 84. BMI 24. Reduced breath sounds bilaterally, no crackles, no wheeze today. No peripheral edema. Post-bronchodilator spirometry: FEV1/FVC 0.58, FEV1 55% predicted. CAT score 18. Soft-mist inhaler technique correct. A: COPD, moderate airflow obstruction, high symptom burden. Symptoms not controlled on single long-acting bronchodilator. P: 1. Change to tiotropium/olodaterol 2.5/2.5 micrograms, 2 inhalations once daily. 2. Pulmonary rehabilitation referral; he agrees. 3. Flu and pneumococcal vaccines today; other vaccines as per local schedule. 4. Written self-management plan for exacerbations reviewed. 5. Review in 8 weeks; repeat CAT score. 6. Urgent care for increasing breathlessness at rest, confusion, chest pain or blue lips.
What the S, O, A and P of a COPD note should carry
In Subjective, give breathlessness a scale (mMRC is common), describe cough and sputum colour and volume, count exacerbations in the past year and say how each was treated and whether admission was needed. Smoking status with pack-years, current inhalers and how often the reliever is used, ankle swelling, weight loss, mood and home circumstances all help.
Objective is where the respiratory rate, oxygen saturation on air, chest findings, signs of right heart strain, BMI, and the post-bronchodilator spirometry values belong, together with a symptom score such as CAT and an observed inhaler technique check.
The Assessment grades airflow obstruction and symptom burden and states exacerbation risk. The Plan lists each inhaler with dose, smoking support or relapse prevention, rehabilitation, vaccines, the self-management plan and rescue pack if given, oxygen assessment if saturations are low, and clear return advice.
Example: COPD exacerbation in clinic
S: 71-year-old woman with COPD, 3 days of more breathlessness, more sputum, now green. No chest pain. Able to eat and drink. Usual exercise tolerance 200 m, now 50 m. O: Temp 37.8, RR 22, SpO2 92% on air (usual 94%), pulse 96, BP 132/78. Alert. Scattered wheeze, no focal crackles. A: Acute exacerbation of COPD with purulent sputum, managed at home. P: Prednisolone 30 mg once daily for 5 days. Amoxicillin 500 mg three times daily for 5 days. Increase salbutamol as needed. Review in 48 hours by phone. Emergency care if breathless at rest, confused or saturation below 90% on a home oximeter.
Gaps that weaken COPD documentation
- Spirometry quoted without saying it was post-bronchodilator.
- Exacerbations described as "a few" rather than a number with treatment and admissions.
- Breathlessness described in words with no scale.
- Smoking status given without pack-years or quit date.
- Oxygen saturation given without stating it was on air.
- Vaccines and rehabilitation offered but not written down, or declined without a note.
ICD-10 codes for COPD
| Code | Meaning |
|---|---|
| J44.9 | Chronic obstructive pulmonary disease, unspecified |
| J44.1 | Chronic obstructive pulmonary disease with (acute) exacerbation |
| J44.0 | Chronic obstructive pulmonary disease with (acute) lower respiratory infection |
| Z87.891 | Personal history of nicotine dependence (ICD-10-CM) |
| F17.210 | Nicotine dependence, cigarettes, uncomplicated (ICD-10-CM) |
When J44.0 is used, a second code for the infection is usually added. Check the rules of the ICD-10 version your system uses.
ClearPass and COPD notes
A COPD review is mostly conversation, which is where Transcribe helps. After the patient agrees, you talk and examine as normal; ClearPass then drafts the note in SOAP with the breathlessness scale, exacerbation count and inhaler history in S and the spirometry and saturations in O. Detailed mode keeps the full exacerbation history; Concise gives a tight review note.
Spirometry percentages and saturations that were not said aloud are marked by the numbers check, so you can add the real values. ICD-10 codes, patient instructions for the self-management plan and a rehabilitation referral letter are each one click. Everything it writes is a draft for you to review.
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
Which scores should a COPD SOAP note include?
Commonly a breathlessness scale such as mMRC and a symptom score such as CAT, alongside exacerbation count and spirometry. Use the ones your service uses and write the number, not just the category.
How do I document an exacerbation managed at home?
State the change from baseline (breathlessness, sputum volume and colour), observations including saturation on air, the treatment with doses and duration, and when and how the patient will be reviewed.
Does ClearPass know the patient's previous spirometry?
No. It writes from this visit only and does not connect to your EMR. If you read out or type the previous values, they go into the note.
What does ClearPass cost?
The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.
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