SOAP note example: upper respiratory infection

Colds and sore throats fill clinic lists, and their notes are often three lines long. The risk is not the common case but the one that turns out to be something else, where a short note leaves no trace of what was checked. The invented notes below are brief but defensible: they show the negatives that matter and the advice given.

Example: viral upper respiratory infection

S: 34-year-old woman, 4 days of runny nose, sore throat, dry cough and feeling hot. Eating and drinking normally. No breathlessness, chest pain, ear pain or facial pain. No rash. Partner had similar symptoms last week. No asthma or other lung disease. Not immunosuppressed. Taking paracetamol with some relief.
O: Temp 37.6, pulse 82, RR 14, SpO2 99% on air. Alert, well hydrated. Mild pharyngeal redness, tonsils not enlarged, no exudate. No tender anterior cervical nodes. Tympanic membranes normal. No sinus tenderness. Chest clear.
A: Viral upper respiratory tract infection. No features of bacterial tonsillitis, pneumonia or sinusitis.
P: 1. Rest, fluids, paracetamol or ibuprofen as needed per packet.
2. Honey and warm drinks for cough.
3. Antibiotics not indicated; reason explained and she agrees.
4. Usual course 7 to 10 days; cough can last up to 3 weeks.
5. Return if breathless, chest pain, fever beyond 5 days, symptoms worsening after initial improvement, or unable to swallow fluids.

Documenting a short visit properly

The Subjective section should date the onset, list the symptoms present and, just as important, the ones asked about and absent: breathlessness, chest pain, ear and facial pain, rash, drooling or inability to swallow. Contacts, vaccination status where relevant, comorbidities that raise risk (lung disease, immunosuppression, pregnancy) and what has already been tried all help.

In Objective, a full set of observations protects both patient and clinician: temperature, pulse, respiratory rate and oxygen saturation. Then the throat (tonsils, exudate), cervical nodes, ears, sinuses and chest. If you use a sore throat score, write its components and the total.

The Assessment names the working diagnosis and the serious alternatives you considered and set aside. The Plan holds symptomatic advice, the antibiotic decision with the reason, the expected duration of illness, and specific return advice. That last line is what most often goes missing.

Example: sore throat with a clinical score

S: 19-year-old man, 2 days of severe sore throat and fever. No cough. Swallowing painful but managing fluids. No voice change, no trismus.
O: Temp 38.4, pulse 96, SpO2 99%. Tonsils enlarged with exudate both sides, uvula central. Tender anterior cervical nodes. Centor score 4 (fever, exudate, nodes, no cough).
A: Acute tonsillitis, likely bacterial. No sign of peritonsillar abscess.
P: Phenoxymethylpenicillin 500 mg four times daily for 10 days. Analgesia. Return same day if unable to swallow fluids, drooling, muffled voice or one-sided throat swelling.

Frequent weaknesses in URI notes

• No observations, especially no oxygen saturation or respiratory rate.
• Only positive findings written, so there is no evidence that red flags were asked.
• Antibiotic decision not explained, or a delayed prescription given without instructions.
• No expected duration, which drives repeat visits.
• Return advice written as "return if worse" instead of specific symptoms.

ICD-10 codes for upper respiratory infections

Pick the most specific site you examined. Base ICD-10 uses J03.9 and J01.9 where ICD-10-CM adds a digit.

Writing a URI note with ClearPass

Short visits are where a scribe saves the most proportionally, because the typing takes as long as the consultation. With Transcribe running (the patient agrees first), the negatives you ask about and the advice you give out loud are captured and placed in SOAP. Concise mode gives the brief note most clinicians want for a cold.

The numbers check marks a temperature or saturation in the note that was not in the transcript. ICD-10 codes are one click, and one more click gives patient instructions with the self-care and return advice, or a sick note if the patient needs time off work. Read and correct the draft before pasting it.

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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