Comprehensive Health Assessment (CHA) Soap Example
Review Content and Examples in Bates’ Chapter, 3, 4, and 5
(NOTE: This is an abbreviated example)
Information
It is important that you do not include information on the CHA SOAP that can identify your patient.
Only list the age, sex, and ethnicity of the patient, and indicate “yes” or ‘no” for health
insurance.
Compose your CHA SOAP in Word using an outline format with headings and subheadings as
illustrated in the example.
You are required to disclose one problem as part of the chief complaint.
A volunteer non-pregnant co-worker or non-pregnant family member or friend age ≥ 13 years who has
a known health problem is the candidate to serve as your “patient” for this assignment. You are not
allowed to use a real patient or yourself for this assignment.
Important Tips
Do not use the term “patient” throughout the CHA SOAP.
Subjective data is what the patient tells you when asked questions about each component of the health
history.
Objective data is what you see, hear, or feel when examining the patient.
When documenting subjective data, especially Review of Systems, do not use the terms “positive,
negative, no, or +/-” as this reflects objective data, what you detect or observe. Be specific with
documenting what the patient tells you.
Other terms that you should avoid in both the Review of Systems and Physical Examination include
“appropriate, intact, normal, unremarkable, or abnormal.” Need to be specific with documenting
subjective and objective data.
✓ Chief Complaint: Should be a short and concise quote using patient’s own words.
• Example: “My throat hurts.” Other information is included in the HPI.
✓ Review of Systems (ROS): This is what the patient tells you when asked about each system listed
on the grading rubric.
• Document data using “Denies” or “Reports.”
• Example ROS General Survey: Denies weight loss, fever, fatigue.
• Example ROS Breasts: Reports pain to breasts during menses. Denies lumps or dimpling.
✓ Physical Examination (PE): This is what you find or observe when examining each system listed
on the grading rubric.
• Example PE Lymphatic: Cervical, supraclavicular, axillary, and inguinal lymph nodes
without enlargement or tenderness.
• Example PE Nose/Sinuses: Mucosa swelling with erythema and yellow thick drainage.
Septum midline. Tenderness over maxillary and frontal sinuses.
Page 1 of 8
Advanced Nursing Assessment
, S – Subjective Data (Health History)
Health History: The health history interview is a conversation with a purpose to help you gather
patient information that is organized in various categories (p.77-110).
• Patient Information: Age/gender/ethnicity, insurance (yes/no), source of
information/reliability (p.81).
➢ Example Patient Information: 25y/o Caucasian male, insurance (yes), patient is a
reliable source of information.
• Chief complaint (CC): Include a brief statement identifying why the patient is seeking care.
Quote patient’s own words (p.81-82).
➢ Example CC: “I’ve been having indigestion”
• History of Present Illness (HPI): Provide a complete, clear, and chronologic account of the
problem. List each attribute and describe the symptom based on the patient’s response (p.82-88,
Box 3-4).
➢ Example HPI using the CC indigestion:
Location: (where is it? does it radiate?) Upper stomach and throat, radiates across chest.
Quality: (what is it like?) Burning sensation.
Quantity/Severity: (how bad is it?) Discomfort from burning sensation rates 6/10.
Timing: Onset (when did it initially start? what was the setting when it occurred?) Sudden
onset 5 days ago when eating at a Mexican restaurant.
Duration (how long does it last?) It can last 2 hours or longer.
Frequency (how often does it occur?) Every day after eating lunch and dinner.
Modifying Factors: (what makes it better or worse? self-treatment?) Eating spicy greasy
foods makes symptoms worse. Cutting back on the amount of food on day 5 decreased
the severity of heartburn. OTC Tums after lunch and dinner provides some relief after
about 2 hours. Discomfort rates 3/10 after taking Tums.
Associated Manifestations: (are there any associated signs or symptoms that accompany
it?) Frequent burping and coughing.
Additional medical or social information relevant to the CC: (is there any medical or
social information relevant to the CC?) Patient believes spicy greasy foods irritate his
stomach and triggers indigestion/heartburn. For the past 5 days, admits to eating
Mexican food, pizza, and fried chicken for lunch and dinner. Treated for H. pylori
gastritis 8 years ago. History of IBS since age 15. Admits to poor dietary habits and
smokes ½ pack cigarettes daily.
Page 2 of 8
Advanced Nursing Assessment
Review Content and Examples in Bates’ Chapter, 3, 4, and 5
(NOTE: This is an abbreviated example)
Information
It is important that you do not include information on the CHA SOAP that can identify your patient.
Only list the age, sex, and ethnicity of the patient, and indicate “yes” or ‘no” for health
insurance.
Compose your CHA SOAP in Word using an outline format with headings and subheadings as
illustrated in the example.
You are required to disclose one problem as part of the chief complaint.
A volunteer non-pregnant co-worker or non-pregnant family member or friend age ≥ 13 years who has
a known health problem is the candidate to serve as your “patient” for this assignment. You are not
allowed to use a real patient or yourself for this assignment.
Important Tips
Do not use the term “patient” throughout the CHA SOAP.
Subjective data is what the patient tells you when asked questions about each component of the health
history.
Objective data is what you see, hear, or feel when examining the patient.
When documenting subjective data, especially Review of Systems, do not use the terms “positive,
negative, no, or +/-” as this reflects objective data, what you detect or observe. Be specific with
documenting what the patient tells you.
Other terms that you should avoid in both the Review of Systems and Physical Examination include
“appropriate, intact, normal, unremarkable, or abnormal.” Need to be specific with documenting
subjective and objective data.
✓ Chief Complaint: Should be a short and concise quote using patient’s own words.
• Example: “My throat hurts.” Other information is included in the HPI.
✓ Review of Systems (ROS): This is what the patient tells you when asked about each system listed
on the grading rubric.
• Document data using “Denies” or “Reports.”
• Example ROS General Survey: Denies weight loss, fever, fatigue.
• Example ROS Breasts: Reports pain to breasts during menses. Denies lumps or dimpling.
✓ Physical Examination (PE): This is what you find or observe when examining each system listed
on the grading rubric.
• Example PE Lymphatic: Cervical, supraclavicular, axillary, and inguinal lymph nodes
without enlargement or tenderness.
• Example PE Nose/Sinuses: Mucosa swelling with erythema and yellow thick drainage.
Septum midline. Tenderness over maxillary and frontal sinuses.
Page 1 of 8
Advanced Nursing Assessment
, S – Subjective Data (Health History)
Health History: The health history interview is a conversation with a purpose to help you gather
patient information that is organized in various categories (p.77-110).
• Patient Information: Age/gender/ethnicity, insurance (yes/no), source of
information/reliability (p.81).
➢ Example Patient Information: 25y/o Caucasian male, insurance (yes), patient is a
reliable source of information.
• Chief complaint (CC): Include a brief statement identifying why the patient is seeking care.
Quote patient’s own words (p.81-82).
➢ Example CC: “I’ve been having indigestion”
• History of Present Illness (HPI): Provide a complete, clear, and chronologic account of the
problem. List each attribute and describe the symptom based on the patient’s response (p.82-88,
Box 3-4).
➢ Example HPI using the CC indigestion:
Location: (where is it? does it radiate?) Upper stomach and throat, radiates across chest.
Quality: (what is it like?) Burning sensation.
Quantity/Severity: (how bad is it?) Discomfort from burning sensation rates 6/10.
Timing: Onset (when did it initially start? what was the setting when it occurred?) Sudden
onset 5 days ago when eating at a Mexican restaurant.
Duration (how long does it last?) It can last 2 hours or longer.
Frequency (how often does it occur?) Every day after eating lunch and dinner.
Modifying Factors: (what makes it better or worse? self-treatment?) Eating spicy greasy
foods makes symptoms worse. Cutting back on the amount of food on day 5 decreased
the severity of heartburn. OTC Tums after lunch and dinner provides some relief after
about 2 hours. Discomfort rates 3/10 after taking Tums.
Associated Manifestations: (are there any associated signs or symptoms that accompany
it?) Frequent burping and coughing.
Additional medical or social information relevant to the CC: (is there any medical or
social information relevant to the CC?) Patient believes spicy greasy foods irritate his
stomach and triggers indigestion/heartburn. For the past 5 days, admits to eating
Mexican food, pizza, and fried chicken for lunch and dinner. Treated for H. pylori
gastritis 8 years ago. History of IBS since age 15. Admits to poor dietary habits and
smokes ½ pack cigarettes daily.
Page 2 of 8
Advanced Nursing Assessment
