Basic SOAP Note Template - ObGyn

Chief Complaint

Comprehensive OB/GYN SOAP Note Template

History of Present Illness

[Provide a thorough narrative of the patient's primary concerns or symptoms, including both current and past symptoms. Use the OPQRST AAA mnemonic (onset, provocation, quality, radiation, severity, time, associated symptoms, alleviating/aggravating factors). Include timing, duration, frequency, severity, associated symptoms, impact on daily life, chronic disease management, immunization status, quantitative details, symptom onset, accidents/injuries, patient quotes, recent labs, concerns, interventions, progress, outcomes, management strategies, diet/lifestyle, reproductive health, psychological/cognitive symptoms, family input, diagnostic studies, and any other relevant details. Use past tense for past events and present tense for current encounter. Exclude treatment recommendations or plans. Use the patient's name if available, otherwise use 'The patient'.] (List items with bullet, and each item in a new line. )

Obstetric History

[Write a comprehensive narrative of the patient's obstetric history, including gravidity and parity, current pregnancy details (gestational age, screening, ultrasound, complications), past pregnancy and delivery outcomes, intervals between pregnancies, reproductive history, and current pregnancy course. Include EDC if mentioned. Do not include statements about absence of information. Use the patient's name if available, otherwise use 'The patient'. If unavailable, enter null.] (List items with bullet, and each item in a new line. )

Gynecologic History

[Provide a detailed narrative of the patient's gynecologic history, including Pap smear history (dates/results), STI history, contraceptive methods (past/present), menstrual cycle regularity, gynecologic surgeries/procedures, and current reproductive plans or concerns. Do not include statements about absence of information. Use the patient's name if available, otherwise use 'The patient'. If unavailable, enter null.] (List items with bullet, and each item in a new line. )

Past Medical History

[Write a comprehensive record of all significant past medical events, chronic diseases, treatments, outcomes, and timeline. Include hospitalizations, ED visits, surgeries, accidents/injuries, community resources, referrals, specialists, recent travel, diagnosed conditions, compliance with medical advice/treatments/follow-ups, missed appointments, and impact of non-compliance. Include pertinent negatives only if directly stated. Exclude current symptoms. Structure as a clear, chronological narrative. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

Past Surgical History

[Provide a detailed narrative of all previous surgical interventions, specifying type, body part, year, surgeon or facility, complications, and relevance to chief complaint or specialty. If no surgical history, clearly state so. Use 'unknown' for any details the patient cannot recall. Only include information explicitly stated. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

Family History

[Document health conditions and diseases affecting the patient's genetic relatives (parents, siblings, children), including hereditary patterns or environmental exposures. Do not include surgical history. Only include information explicitly stated. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

Social History

[Write a narrative of the patient's social history, including home/work environment, education, employment, social activities, drug/alcohol/tobacco use, sexuality, dietary habits, exercise, disability tax credit, and relevant partner health information if provided. Only include information explicitly mentioned. Do not include statements about absence of information. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

The Review of Systems

[Systematically review symptoms reported by the patient across all body systems discussed in the encounter. Organize by system, listing each system followed by the patient's reported symptoms or pertinent negatives. Include the patient's perspective, feelings, fears, and expectations. Do not include physician exam findings or duplicate HPI content. Only include systems and symptoms explicitly discussed. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

Current Medications

[List all current medications, including over-the-counter and supplements, with name, dosage, frequency, and route. Include birth control if relevant. Explicitly document adherence, understanding, recall, attitudes, and any inability to recall or neglect. Include all discussed medication side effects and education provided. Do not include new medications prescribed during this encounter. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

Allergies

[Document all known allergies to medications, foods, environmental agents, anesthetics, adhesives, and latex. Include explicit confirmation of no known allergies if stated. Exclude allergy testing performed during the encounter. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

Estimated Date of Confinement

[Document the estimated date of confinement (EDC) if mentioned. Use the patient's name if available, otherwise use 'The patient'. If not mentioned, enter null.]

Vital Signs

[Log all reported vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, pain level) and any assessment scores (e.g., PHQ-9, GAD-7) if available. Only include if specific measurements are reported. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.]

Physical Examination

[Write a detailed narrative of the physical examination, including both normal and abnormal findings, examination techniques, and measurements (weight, height, BMI). Convert units and calculate BMI if necessary. Include details of endoscopic exams, biopsies, and specimen collection if performed. Use formal medical terminology. Do not include statements about absence of information. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

Investigations

[Enter laboratory test results and results of any questionnaires or assessment scales (e.g., Epworth, PHQ-9, GAD-7, MMSE, VAS). Write each key result as a complete sentence using formal medical terminology. Only include information explicitly stated. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

Problem

[List current obstetrical and non-obstetrical issues, ordered by importance, with ICD-9 codes. If no explicit diagnosis, use signs, symptoms, or exam findings related to chief complaints. Do not use prefixes or bullet points. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.]

Differential Diagnosis

[Summarize the differential diagnosis as a list of potential diagnoses not already in the Problem section, each followed by a brief explanation based on symptoms, history, exam, and test results. Only include if the doctor conducted a DDx during the encounter. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

Plan

[List the comprehensive plan for the patient, including actions already taken (past tense) and next steps (present/future tense). Include test orders, medication details (name, dosage, frequency), therapy referrals, lifestyle modifications, referrals (with specialist name, specialty, reason, urgency), follow-up details (date/time/purpose), alternative plans, external resources, medication side effect discussions, patient education (only if explicitly provided), monitoring targets, and rationale for therapies. Separate each item with a newline. Do not use prefixes or bullet points. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

Plan

[List the comprehensive plan for the patient, including actions already taken (past tense) and next steps (present/future tense). Include test orders, medication details (name, dosage, frequency), therapy referrals, lifestyle modifications, referrals (with specialist name, specialty, reason, urgency), follow-up details (date/time/purpose), alternative plans, external resources, medication side effect discussions, patient education (only if explicitly provided), monitoring targets, and rationale for therapies. Separate each item with a newline. Do not use prefixes or bullet points. Use the patient's name if available, otherwise use 'The patient'. If not stated, enter null.] (List items with bullet, and each item in a new line. )

Surgery Discussion

[If surgery is discussed, provide details on: Purpose of the Surgery, Risks and Complications, Anesthesia, and Alternatives. If any component is not present, enter 'N/A' for that component. If only a recommendation is made, all components should be 'N/A'. Use the patient's name if available, otherwise use 'The patient'.]