Nightingale College
BSN 246 Chapter 12 Adult Health Physical Assessment
Comprehensive SOAP Notes Documentation Mental Status
Examination Subjective Objective Data Review of Systems
OLDCARTS Symptom Analysis Patient History Clinical
Interview Nursing Assessment Diagnostic Planning Care
Documentation Guide Exam Questions Verified and
Provided with Complete A+ Graded Answers Latest
Updated 2026
SOAP (subjective, objective, assessment, plan) notes
Mental Status
Objective
Physical appearance
Behavior
Facial Expression
Body language
Appropriate Eye contact
Level of consciousness
Response to questions
Reasoning
Emotion
Speech
,Language
SOAP (subjective, objective, assessment, plan) notes
Format for documenting client data including health history, physical examination,
assessment or diagnosis, and plan of care
SOAP (subjective, objective, assessment, plan) notes
Identifying client information
Subjective
Name
Date of Birth
Medical Record Number
SOAP (subjective, objective, assessment, plan) notes
PAMI (Problems, Allergies, Medications, Immunizations list)
Subjective
Ongoing list of medical problems, allergies with reactions, medications with dosages and
directions, and past immunizations.
SOAP (subjective, objective, assessment, plan) notes
General client information
Subjective
Address
,Phone number
Employer
Work address and phone number
Email address
Gender
Marital status
Health insurance status and information
SOAP (subjective, objective, assessment, plan) notes
Chief complain or reason for seeking care
Subjetive
Brief description of main problem; stated verbatim in quotation marks; duration is always
included.
SOAP (subjective, objective, assessment, plan) notes
History of present illness
Subjetive
Detailed description of all symptoms that may be related to the chief complain.
Guided by OLDCARTS symptoms analysis (Onset, Location, Duration, Character,
Aggravating/associated factors, Relieving factors, Timing, Severity)
SOAP (subjective, objective, assessment, plan) notes
Past medical history
Subjetive
, Hospitalizations
Surgeries,
Childhood illnesses
Adult illnesses
Injuries/Accidents
Immunizations
Past and current medications
Allergies
Mental Health
Recent laboratory tests
SOAP (subjective, objective, assessment, plan) notes
Family History
Subjective
Pedigree may be included
Includes but not limited to major health or genetic disorder such as hypertension, cancer,
cardiac, respiratory, and thyroid disorders, allergies, hepatitis.
Age and health of spouse and children included
SOAP (subjective, objective, assessment, plan) notes
Personal and social history
Subjetive
Varies based on:
Health influences
BSN 246 Chapter 12 Adult Health Physical Assessment
Comprehensive SOAP Notes Documentation Mental Status
Examination Subjective Objective Data Review of Systems
OLDCARTS Symptom Analysis Patient History Clinical
Interview Nursing Assessment Diagnostic Planning Care
Documentation Guide Exam Questions Verified and
Provided with Complete A+ Graded Answers Latest
Updated 2026
SOAP (subjective, objective, assessment, plan) notes
Mental Status
Objective
Physical appearance
Behavior
Facial Expression
Body language
Appropriate Eye contact
Level of consciousness
Response to questions
Reasoning
Emotion
Speech
,Language
SOAP (subjective, objective, assessment, plan) notes
Format for documenting client data including health history, physical examination,
assessment or diagnosis, and plan of care
SOAP (subjective, objective, assessment, plan) notes
Identifying client information
Subjective
Name
Date of Birth
Medical Record Number
SOAP (subjective, objective, assessment, plan) notes
PAMI (Problems, Allergies, Medications, Immunizations list)
Subjective
Ongoing list of medical problems, allergies with reactions, medications with dosages and
directions, and past immunizations.
SOAP (subjective, objective, assessment, plan) notes
General client information
Subjective
Address
,Phone number
Employer
Work address and phone number
Email address
Gender
Marital status
Health insurance status and information
SOAP (subjective, objective, assessment, plan) notes
Chief complain or reason for seeking care
Subjetive
Brief description of main problem; stated verbatim in quotation marks; duration is always
included.
SOAP (subjective, objective, assessment, plan) notes
History of present illness
Subjetive
Detailed description of all symptoms that may be related to the chief complain.
Guided by OLDCARTS symptoms analysis (Onset, Location, Duration, Character,
Aggravating/associated factors, Relieving factors, Timing, Severity)
SOAP (subjective, objective, assessment, plan) notes
Past medical history
Subjetive
, Hospitalizations
Surgeries,
Childhood illnesses
Adult illnesses
Injuries/Accidents
Immunizations
Past and current medications
Allergies
Mental Health
Recent laboratory tests
SOAP (subjective, objective, assessment, plan) notes
Family History
Subjective
Pedigree may be included
Includes but not limited to major health or genetic disorder such as hypertension, cancer,
cardiac, respiratory, and thyroid disorders, allergies, hepatitis.
Age and health of spouse and children included
SOAP (subjective, objective, assessment, plan) notes
Personal and social history
Subjetive
Varies based on:
Health influences
