OB/GYN Ambulatory SOAP Note

Date of Service: [Date]
Patient: [Full name, DOB, MRN]
Provider: [Name, credentials]
Pregnancy Status: [Pregnant with GA/EDD and dating basis / Not pregnant / Postpartum day/week]

Subjective

Chief Concern: [One-line reason for visit]

HPI: [Narrative history of present illness] (Describe onset, duration, course, severity, exacerbating/relieving factors, prior evaluations and responses, and pertinent negatives that meaningfully narrow the differential. Include patient goals and preferences when relevant to the plan. For pregnant patients, include bleeding, fluid loss, contractions, fetal movement, and preeclampsia warning signs as appropriate to gestational age. For gynecologic concerns, include LMP, cycle pattern, bleeding characteristics, pelvic pain features, and discharge as relevant. Document only clinically pertinent information—do not pad for completeness.)

Pertinent History: [OB history (G/P, relevant prior complications), GYN history (menstrual pattern, contraception, cervical screening, STI history, prior procedures), medical/surgical history, current medications with doses for high-risk drugs, allergies, relevant family/social history] (Include only elements that affect today's assessment or management. For IPV/safety screening, document that screening occurred privately, patient's response, and resources offered if positive; if deferred, note reason. If clinically relevant information is unavailable, document as explicitly unknown.)

Objective

Vitals: [BP, HR, Temp, RR, SpO2, weight as relevant; fundal height and FHR for prenatal visits]

Exam: [Pertinent findings by system examined] (Document systems examined with pertinent positives and negatives. State "deferred" or "not indicated" for exams not performed rather than omitting silently. Do not auto-populate normal findings unless actually assessed.)

Sensitive Exams: (Include only if breast, pelvic, or rectal exam performed. Never infer consent or chaperone presence.)

• Breast exam: [Indication]; Consent obtained: [yes/no]; Chaperone: [Name, role / Patient declined chaperone]; [Findings]
• Pelvic exam: [Indication]; Consent obtained: [yes/no]; Chaperone: [Name, role / Patient declined chaperone]; External: [findings]; Speculum: [findings]; Bimanual: [findings]
• Rectal exam: [Indication]; Consent obtained: [yes/no]; Chaperone: [Name, role / Patient declined chaperone]; [Findings]

Data: [Relevant labs, imaging, and point-of-care test results with dates and interpretation; note pending results with follow-up plan]

Assessment

[Problem list in order of clinical priority with working diagnosis, key supporting findings, differential if uncertainty is clinically meaningful, and severity/risk framing] (Do not list stable chronic conditions unless addressed today. For pregnant patients, include current GA, EDD with dating basis, and relevant pregnancy course highlights.)

Plan

[Problem-oriented plan with diagnostics, therapeutics (medication name/dose/route/frequency/duration), counseling and shared decision-making, referrals, and follow-up timing for each problem addressed]

Return Precautions: [Symptoms warranting urgent evaluation in patient-friendly language]

Postpartum-specific: [Mood screening tool and result; bleeding/infection guidance; contraception plan] (Include only for postpartum visits. Document tool used, score, and plan if positive for mood screening. For sterilization, document counseling and consent timing per federal requirements.)