A respiratory note that shows how hard the patient is working to breathe, records SpO2 with its oxygen source, and uses a severity score to justify outpatient care.
By Francisco Sanchez, BSN, RN · ER nurse and FNP student · Updated October 2026
3 days of fever to 102.1 °F with chills, cough productive of rust-colored sputum, and right-sided chest pain with deep breaths. Mild shortness of breath on stairs; none at rest. No hemoptysis or leg swelling. Eating and drinking. No hospitalization or antibiotics in the past 90 days, no recent travel.
Smoking / exposures
Never smoker; does not vape. Office worker. No known TB exposure.
Baseline
No lung disease, home oxygen or prior intubations. No heart, liver or kidney disease, diabetes, alcohol use disorder, cancer or asplenia. Alcohol 2-3 drinks a week.
Meds
Ibuprofen as needed for fever. No inhalers. No known drug allergies. No flu vaccine yet this season.
OObjective
Vital signs
T 101.4 °F, HR 104, RR 22, BP 128/80. SpO2 94% on room air at rest; 93% on room air after walking the hallway.
Exam
Mildly ill appearing. Speaks in full sentences; no accessory muscle use or cyanosis. Right base: crackles, bronchial breath sounds, egophony and dullness to percussion. Left lung clear. Tachycardic, regular rhythm. Oriented and alert.
Data
Chest X-ray (2 views): right lower lobe consolidation, no effusion. Influenza and SARS-CoV-2 PCR negative. BUN 14. CURB-65 score 0.
AAssessment
Diagnosis
Community-acquired pneumonia, right lower lobe, low severity (CURB-65 0). Oxygen saturation adequate on room air, no increased work of breathing, tolerating oral intake: appropriate for outpatient treatment. No comorbidities or risk factors for resistant organisms. Pulmonary embolism less likely (fever with focal consolidation, low pretest probability).
Amoxicillin 1 g by mouth three times daily for 5 days, provided he is afebrile and stable by then (doxycycline 100 mg twice daily if amoxicillin isn't tolerated). Acetaminophen 650 mg every 6 hours as needed for fever (maximum 3 g a day). Oxygen: none needed; goal SpO2 92% or higher on room air.
Education
Rest and fluids; cough may last a few weeks. Influenza vaccine once recovered. Return or go to the ED for worsening shortness of breath, SpO2 below 92% on a home oximeter, confusion, chest pain that worsens, inability to keep fluids or medicines down, or fever beyond 72 hours on antibiotics.
Follow-up
Phone check in 48 hours; clinic visit in 1 week. No routine follow-up chest X-ray if symptoms resolve.
Fictional patient, written for learning. Follow your program's and facility's documentation standards.
Why this note works
SpO2 is recorded with its oxygen source, at rest and with exertion.
Work of breathing is described (full sentences, no accessory muscles), not just a number.
A validated severity score supports the decision to treat at home.
The plan states an oxygen goal and gives specific reasons to return.
What students often miss
Oxygen source with every SpO2
Baseline function or home oxygen
Inhaler technique and adherence
Pulmonology SOAP note template
How hard is the patient working to breathe, and why?
Reading examples helps. Writing your own note and seeing exactly what you missed is what makes you better. SOAPy gives you a realistic case and checks your note section by section.