Illustrative example
SOAP note
Subjective. 54-year-old with 3 days of productive cough and low-grade fever to 100.4 F. Mild shortness of breath on stairs. No chest pain. Non-smoker. Taking lisinopril 10 mg daily.
Objective. T 99.9 F, HR 92, BP 132/84, SpO2 96% on room air. Crackles at the right base. No wheeze.
Assessment. Suspected community-acquired pneumonia, right lower lobe, outpatient-appropriate.
Plan. Chest X-ray today. Start antibiotic per clinician choice. Return precautions reviewed. Follow up in 48 to 72 hours or sooner if worse.