Respiratory Therapy SOAP Notes: Complete Documentation Guide

Written by SOAPNoteAI Editorial Team · Updated June 2026

Respiratory therapists (RTs) and pulmonologists document some of the most clinically complex encounters in healthcare — from interpreting arterial blood gases and managing mechanical ventilation in the ICU to conducting pulmonary function tests and managing chronic obstructive pulmonary disease in outpatient clinics. Respiratory therapy SOAP notes must capture precise physiologic data, evolving ventilator strategies, and nuanced pulmonary exam findings that directly guide life-support decisions.

This guide covers SOAP note documentation across the full spectrum of respiratory therapy practice settings: acute care (ICU and hospital), emergency department, and outpatient pulmonology.

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Unique Aspects of Respiratory Therapy Documentation

1. Physiologic Data Precision: ABG values, SpO2, FiO2, and spirometry numbers must be exact
2. Time-Sensitive Documentation: Ventilator changes and emergency RT interventions require timestamped entries
3. Ventilator Management: Complex multi-parameter documentation with safety thresholds
4. Treatment Response: Pre/post documentation for bronchodilator treatments, CPT, and suctioning
5. Equipment Documentation: Device settings, mask fit, circuit changes, and filter changes
6. Scope of Practice Documentation: RT-driven protocols require clear documentation of clinical decision-making authority

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Part 1: Hospital and ICU Respiratory Therapy Notes

Subjective Section (S) — Acute Care RT

For ventilated or critically ill patients, subjective data may come from family members or nursing staff rather than the patient.

Subjective Components (Acute Care)

1. Patient History (relevant to respiratory status):

   • Primary diagnosis and reason for respiratory support
   • Pulmonary history (COPD, asthma, IPF, OSA, neuromuscular disease)
   • Smoking history (pack-year calculation)
   • Allergies, especially to bronchodilators

2. Current Complaint / Interval Change:

   • Patient-reported: dyspnea rating (0-10 Borg scale), chest tightness, secretions
   • Nursing report: changes in ventilator alarms, secretion character, agitation

3. Secretion Management:

   • Frequency and color of secretions (clear, white, yellow, green, brown)
   • Cough strength (strong, weak, absent)
   • Suctioning frequency required

4. Tolerance:

   • Tolerance to current therapy, positioning, or weaning trials
   • Sedation/agitation level (RASS score)

Objective Section (O) — Mechanical Ventilation

This section requires the most detailed documentation in respiratory therapy notes.

Vital Signs and Oxygenation Status

1. Vital Signs:

   • Respiratory rate (set vs. total — patient-triggered above set rate)
   • SpO2 and current FiO2 (always document both together)
   • Heart rate and blood pressure (relevant to ventilatory response)
   • Temperature (fever affects metabolic demand and CO2 production)

2. Arterial Blood Gas (ABG) Values:

   • Document all parameters: pH, PaCO2, PaO2, HCO3, Base Excess, SaO2
   • Time drawn (critical for interpretation context)
   • Interpretation: primary disorder + compensation + oxygenation status

Current Ventilator Settings

Document ALL of the following for mechanically ventilated patients:

Parameter	Normal Range	Document
Mode	A/C, SIMV, CPAP/PS, PRVC	Current mode
Tidal Volume (VT)	6-8 mL/kg IBW	mL and mL/kg IBW
Set Rate	Varies	breaths/min
Total Rate	Includes patient-triggered	breaths/min
FiO2	0.21-1.0	as decimal or %
PEEP	5-20+ cmH2O	cmH2O
Pressure Support	5-20 cmH2O	cmH2O above PEEP
Peak Inspiratory Pressure (PIP)	<40 cmH2O	cmH2O
Plateau Pressure (Pplat)	<30 cmH2O	cmH2O
Driving Pressure (ΔP)	<15 cmH2O	cmH2O
Mean Airway Pressure (MAP)	Varies	cmH2O

Breath Sounds and Physical Assessment

• Auscultation: Document each lung field (right upper, right lower, left upper, left lower)
  • Clear, diminished (bilateral/unilateral), wheezes (inspiratory/expiratory), crackles (fine/coarse), rhonchi
• Work of Breathing: Accessory muscle use, retractions (subcostal, intercostal, suprasternal), nasal flaring, paradoxical breathing
• ETT/Trach Position: Centimeter mark at lip/teeth, bilateral chest rise confirmation
• Cuff Pressure: Document and adjust to 20-30 cmH2O

Assessment Section (A) — ICU RT Note

1. Ventilatory Status: Document current mode and reason for mechanical ventilation
2. ABG Interpretation: State primary disorder, compensation, and oxygenation (P:F ratio for ARDS classification)
3. Lung Protection: Are tidal volumes lung-protective (6-8 mL/kg IBW)? Is driving pressure <15 cmH2O?
4. Weaning Readiness: Document current RSBI (f/VT) — <105 suggests readiness for SBT
5. Oxygen Requirements: SpO2 trend on current FiO2; any changes needed

Example Assessment:

Day 4 of mechanical ventilation for ARDS secondary to septic pneumonia. A/C-VC at 6 mL/kg IBW, PEEP 12, FiO2 0.55. ABG shows partially compensated metabolic acidosis with adequate oxygenation (P:F ratio 168 — moderate ARDS). Driving pressure 12 cmH2O (within lung-protective range). No weaning readiness today — RASS -2, febrile to 38.8°C, FiO2 >0.50. Continue lung-protective strategy; prone positioning discussed with team for P:F <150.

Plan Section (P) — ICU RT Note

1. Ventilator Management:

   • Continue current settings vs. specific adjustments (increase PEEP by 2, decrease FiO2 to 0.45)
   • Protocol-driven changes with rationale

2. Weaning Plan:

   • SBT (spontaneous breathing trial) scheduled — time, method (T-piece vs. CPAP/PS trial), pass criteria
   • RSBI calculation and target

3. Treatments Ordered:

   • Nebulized medications (albuterol, ipratropium, budesonide, dornase alfa for CF)
   • Chest physiotherapy / percussion frequency
   • High-flow nasal cannula (HFNC) parameters if transitioning

4. Disposition:

   • Continue mechanical ventilation
   • Trial of HFNC or NIPPV as step-down
   • Extubation plan and post-extubation monitoring

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Part 2: Emergency Department RT Notes

Acute Asthma Exacerbation

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Part 3: Outpatient Pulmonology SOAP Notes

COPD Follow-Up Note

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Weaning and Extubation Documentation

Spontaneous Breathing Trial (SBT) Documentation

When a patient meets SBT criteria, document:

1. Pre-SBT Checklist:

   • Cause of respiratory failure addressed or improving
   • FiO2 ≤0.50, PEEP ≤8 cmH2O
   • Adequate oxygenation (SpO2 >90%, P:F ratio >150)
   • Hemodynamically stable (minimal/no vasopressors)
   • Awake and cooperative (RASS ≥-1), following commands
   • No uncontrolled agitation, seizures, or elevated ICP

2. SBT Method and Duration:

   • Method: T-piece, CPAP 5 cmH2O, or low-level PS (5 cmH2O)
   • Duration: 30-120 minutes

3. SBT Outcome Criteria (Pass):

   • SpO2 ≥90%, RR ≤35/min, VT ≥4 mL/kg IBW
   • RSBI (f/VT) <105 during SBT
   • No signs of distress (tachycardia, hypertension, diaphoresis, accessory muscle use)
   • Alert and cooperative throughout

4. Extubation Documentation:

   • Post-extubation oxygen delivery ordered (NC, simple mask, HFNC)
   • Post-extubation stridor management plan
   • Time of extubation and patient tolerance noted

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AI-Assisted Respiratory Therapy Documentation

Respiratory therapy involves frequent, rapid documentation — especially during ICU rounds when a single RT may manage 8-12 ventilated patients. AI ambient documentation tools can significantly reduce documentation burden.

How AI Helps RT Documentation

• Ventilator rounds: AI can capture verbal reporting of vent settings, ABG values, and assessment findings during verbal rounds handoffs
• Treatment notes: Captures pre/post bronchodilator assessment discussions
• SBT documentation: Structures the checklist and outcome in real time

What to Always Verify in AI-Generated RT Notes

1. Ventilator numbers — tidal volume, PEEP, FiO2 must match the actual vent display
2. ABG values — digits are critical; verify pH, PaCO2, PaO2 against the lab printout
3. Timestamps — weaning trials and SBTs require accurate timing
4. ETT/Trach position — centimeter marking must be exact
5. Suction technique — verify open vs. closed circuit, sterile technique documented

Verbal Cues for Better AI Capture in RT Settings

• "Albuterol treatment completed — post-treatment SpO2 improved from 91% to 96% on 2 liters"
• "Ventilator settings: assist-control, tidal volume 420 mL — that is 6 milliliters per kilogram ideal body weight — rate set 16, total rate 18, PEEP 10, FiO2 50 percent"
• "ABG results: pH 7.38, PaCO2 44, PaO2 88, bicarb 26, saturation 97%, collected at 0800"
• "Spontaneous breathing trial completed — patient passed at 30 minutes; extubation completed at 1045"

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Frequently Asked Questions

Frequently Asked Questions

What should be included in the objective section of a respiratory therapy SOAP note?

The objective section for respiratory therapy should include: current respiratory rate (normal 12-20/min), oxygen saturation (SpO2) with FiO2 or flow rate specified, breath sounds on auscultation (clear, diminished, wheezes, crackles, rhonchi), work of breathing (use of accessory muscles, retractions, nasal flaring), peak flow or spirometry results if measured, arterial blood gas (ABG) or capillary blood gas values (pH, PaCO2, PaO2, HCO3, SaO2), ventilator settings for intubated patients, and sputum characteristics.

How do I document ventilator settings in a SOAP note?

Document all current ventilator settings and patient response: mode (A/C, SIMV, CPAP/PS, BiPAP), tidal volume (VT) in mL and mL/kg ideal body weight, respiratory rate set and total (including patient-triggered breaths), PEEP (positive end-expiratory pressure), FiO2, peak inspiratory pressure (PIP), plateau pressure (should be <30 cmH2O), inspiratory flow, and I:E ratio. Include patient-ventilator synchrony assessment and any auto-PEEP concerns. Note weaning parameters if applicable (RSBI, NIF, VC).

What ABG values are considered normal and how do I interpret them in notes?

Normal ABG values: pH 7.35-7.45 (acidosis <7.35, alkalosis >7.45), PaCO2 35-45 mmHg (elevated = respiratory acidosis, low = respiratory alkalosis), PaO2 80-100 mmHg, HCO3 22-26 mEq/L (elevated = metabolic alkalosis, low = metabolic acidosis), SaO2 >95%. When documenting, state the primary disorder, any compensation, and oxygenation status. Example: 'ABG: pH 7.32, PaCO2 58, PaO2 62, HCO3 28, SaO2 91% on 4L NC — partially compensated respiratory acidosis with hypoxemia.'

How do I document a nebulizer treatment in a SOAP note?

Document: medication name and dose (e.g., albuterol 2.5 mg in 3 mL NS), delivery device (small volume nebulizer, high-flow nebulizer, MDI with spacer), duration, patient cooperation and technique, pre-treatment assessment (SpO2, breath sounds, peak flow if obtainable), post-treatment response (improved breath sounds, SpO2 change, symptom relief, peak flow improvement), and any adverse effects (tachycardia, tremor, paradoxical bronchospasm).

What documentation is required for CPAP and BiPAP therapy?

For CPAP: document prescribed pressure (cmH2O), mask type and fit (nasal pillow, nasal mask, full face), compliance data (hours/night from device download), leak rate, AHI with therapy (target <5/hr), residual events (central vs. obstructive), and patient-reported symptom improvement (Epworth Sleepiness Scale score, energy level). For BiPAP: add IPAP and EPAP settings, backup rate if applicable, and the clinical indication (COPD, OHS, neuromuscular disease).

How do I write a SOAP note for a pulmonary function test interpretation?

Subjective: document patient's chief complaint (dyspnea, cough, wheezing), smoking history (pack-years), occupational exposures, and current bronchodilator use. Objective: report FVC (% predicted), FEV1 (% predicted), FEV1/FVC ratio, and TLC/DLCO if measured. Assessment: classify as normal, obstructive (FEV1/FVC <0.70), restrictive (FVC <80% predicted, normal ratio), or mixed pattern; note severity (mild/moderate/severe/very severe per GOLD criteria). Plan: bronchodilator response, oxygen need, pulmonology referral, or treatment adjustment.

Is there an AI tool for respiratory therapy SOAP note documentation?

Yes, SOAPNoteAI.com provides AI-assisted documentation designed for respiratory therapists and pulmonologists. The platform understands RT-specific terminology including ventilator management, ABG interpretation, pulmonary function testing, and aerosolized medication protocols. It is HIPAA-compliant with a signed Business Associate Agreement (BAA) and available as an iPhone and iPad app. AI documentation tools can reduce the time spent on ventilator rounds notes and treatment notes significantly.