Comprehensive Health Assessment SOAP Note Template
Below is a complete, exam-ready SOAP note structure. Each
section includes the required documentation and the specific
physical exam sequence you must follow.
HEADER / IDENTIFYING DATA
Field Your Documentation
Patient Initials
Age / Gender
Date of Visit
Source of History Patient / Family / Chart (note reliability)
【Documentation Note】 The header establishes the context
for the entire note and is required for every SOAP note
submission.
S — SUBJECTIVE DATA (25 points possible)
Chief Complaint (CC): One brief statement in the patient's own
words.
, History of Present Illness (HPI): Use OLDCARTS to characterize
the chief complaint.
OLDCARTS Element Your Documentation
Onset When did it start?
Location Where is it? Point to it.
Duration How long does it last?
Characteristics What does it feel like?
Aggravating/Alleviating What makes it better or worse?
Radiation Does it move anywhere?
Timing Constant or intermittent?
Severity Rate 0–10.
Past Medical History (PMH): Chronic illnesses, hospitalizations,
surgeries, injuries.
Medications: Name, dose, route, frequency. Include OTCs and
supplements.
Allergies: Medication and environmental, with reaction noted.
Below is a complete, exam-ready SOAP note structure. Each
section includes the required documentation and the specific
physical exam sequence you must follow.
HEADER / IDENTIFYING DATA
Field Your Documentation
Patient Initials
Age / Gender
Date of Visit
Source of History Patient / Family / Chart (note reliability)
【Documentation Note】 The header establishes the context
for the entire note and is required for every SOAP note
submission.
S — SUBJECTIVE DATA (25 points possible)
Chief Complaint (CC): One brief statement in the patient's own
words.
, History of Present Illness (HPI): Use OLDCARTS to characterize
the chief complaint.
OLDCARTS Element Your Documentation
Onset When did it start?
Location Where is it? Point to it.
Duration How long does it last?
Characteristics What does it feel like?
Aggravating/Alleviating What makes it better or worse?
Radiation Does it move anywhere?
Timing Constant or intermittent?
Severity Rate 0–10.
Past Medical History (PMH): Chronic illnesses, hospitalizations,
surgeries, injuries.
Medications: Name, dose, route, frequency. Include OTCs and
supplements.
Allergies: Medication and environmental, with reaction noted.
