, Comprehensive Health Assessment (CHA) SOAP Note
Patient Information:
• Age: 32 y/o
• Sex: Male
• Race: Caucasian
• Insurance: Yes
Source of Information: Patient is awake, alert, and oriented x4; behavior is appropriate to the situation
and appears to be a reliable source.
S – SUBJECTIVE DATA
Chief Complaint (CC):
"I have been coughing for about 2-3 weeks now ... first, it was just a dry cough but now it looks green. I
am a fireman and a couple days ago on shift, while going on a medical call, I felt short of breath which is
not normal for me."
History of Present Illness (HPI) – OLDCARTS Format:
Component Finding
Onset Symptoms began approximately 2-3 weeks ago
Location Discomfort localized to the anterior portion of the chest
Duration Cough consistent throughout the day
"Constant, dull ache" occurring with coughing; "intermittent sharp, stabbing pain" with deep
Character
breaths
Severity Rates discomfort as 6 on a scale of 1-10
Patient Information:
• Age: 32 y/o
• Sex: Male
• Race: Caucasian
• Insurance: Yes
Source of Information: Patient is awake, alert, and oriented x4; behavior is appropriate to the situation
and appears to be a reliable source.
S – SUBJECTIVE DATA
Chief Complaint (CC):
"I have been coughing for about 2-3 weeks now ... first, it was just a dry cough but now it looks green. I
am a fireman and a couple days ago on shift, while going on a medical call, I felt short of breath which is
not normal for me."
History of Present Illness (HPI) – OLDCARTS Format:
Component Finding
Onset Symptoms began approximately 2-3 weeks ago
Location Discomfort localized to the anterior portion of the chest
Duration Cough consistent throughout the day
"Constant, dull ache" occurring with coughing; "intermittent sharp, stabbing pain" with deep
Character
breaths
Severity Rates discomfort as 6 on a scale of 1-10
