Quick Way to Write Gyn SOAP Note Examples for Healthcare Providers

Gyn SOAP Note Examples

It's the end of a long clinic day, and you're staring at your schedule.

Fifteen well-woman exams. Four abnormal bleeding complaints. Two patients with pelvic pain. One IUD insertion. And you haven't finished a single note.

You know each visit needs proper documentation - especially the abnormal findings and procedures - but you're exhausted and your brain feels like mush.

Sound familiar? If you've ever found yourself in these shoes, keep on reading.

We've all been here.

Quick Tip:

SOAP Notes Doctor is our product that transforms recordings, audios, and text into industry-standard SOAP notes.

You can let it listen to your patient encounters and do the work.

You can add, edit, review, and add more context later.

Head over to soapnotes.doctor now.

Let's dive in.

SOAP Notes: The Quick Story

Back in the day, gynecology documentation was all over the place.

One provider might write "normal pelvic exam" while another would document every detail of the speculum exam, bimanual, and patient education in paragraph form that took ten minutes to read.

There was no consistency, and heaven help you if you needed to review a colleague's notes to understand what happened at a previous visit.

Then in the late 1960s, Dr. Lawrence Weed said "there has to be a better way" and created the Problem-Oriented Medical Record with SOAP notes at its foundation.

His brilliant idea was simple: give everyone the same template so any healthcare provider could read someone else's notes and quickly understand the patient's story.

Here's what Dr. Weed came up with:

• S (Subjective): What the patient tells you about their symptoms, concerns, or reason for visit
• O (Objective): What you observe and measure during the examination
• A (Assessment): Your professional clinical judgment about what's going on
• P (Plan): What you're going to do about it

This format spread everywhere because it just worked.

For gynecology specifically, this structure became essential because you need to capture menstrual history, symptoms, exam findings, screening results, and treatment plans - all in a way that's clear, concise, and defensible.

How to Write Gyn SOAP Notes: My Recommended Approach

When I started working with gynecologists and women's health providers, I noticed they'd agonize over every detail in their documentation.

Then I discovered something that changed everything:

"Document what matters clinically. Everything else is noise."

Get the menstrual history, the complaint, the exam findings, and the plan. That's your core. You can always add more if something's unusual, but don't let perfect be the enemy of done.

I picked this approach up from watching the most efficient providers work, and I built soapnotes.doctor around it.

There are technically two ways you can approach gyn SOAP notes. You can write them manually, or you can use soapnotes.doctor.

Use soapnotes.doctor

I'll choose soapnotes.doctor every single time because it's consistent, captures the details that matter, and most importantly, it's way faster than typing everything out yourself.

Here's how to streamline the whole process:

1. Head over to soapnotes.doctor to get started. Complete the onboarding process if you're new to the platform.

2. Click on the record button to either record the patient encounter or dictate your findings after the visit.

3. Wait 1-3 minutes.

4. Review and save.

One beauty of soapnotes.doctor is that it just gets it right. Not overly detailed, yet never misses the critical components. I think that's exactly where you want to be.

And if you need to make edits, you have the tailorr feature at your disposal. Edit, approve, add context, and copy straight to your EHR.

Write Manually

Maybe you prefer typing it out yourself, or maybe your institution requires manual entry. Here's how to do it efficiently.

1. S - Subjective

This is where you capture the patient's story and reason for visit.

This section should document what your patient tells you about their symptoms, concerns, or what brought them in today.

Purpose: Document the patient's perspective on their gynecological health and any concerns.

What to include:

• Chief complaint or reason for visit
• Menstrual history (LMP, cycle regularity, flow)
• Current symptoms (bleeding pattern, pain, discharge)
• Sexual history when relevant
• Contraception use and satisfaction
• Previous treatments tried
• Impact on daily life

Examples:

"Patient presents for annual well-woman exam. LMP 2 weeks ago, regular 28-day cycles. Denies abnormal bleeding, pelvic pain, or unusual discharge. Currently using oral contraceptive pills for past 2 years with good tolerance. Sexually active in monogamous relationship. No dyspareunia. Last Pap smear 3 years ago was normal."

"Patient reports heavy menstrual bleeding for past 4 months. Soaking through super tampon every 1-2 hours on heaviest days. Periods lasting 8-9 days, previously 5 days. LMP 2 weeks ago. Denies intermenstrual bleeding or postcoital bleeding. Reports fatigue and some dizziness during period. No abdominal pain. Using pads and tampons, considering IUD for contraception."

2. O - Objective

This is where you document what you observe and measure.

The objective section is where you record your clinical findings from the examination.

Purpose: Document measurable, observable data from the gynecological examination.

What to include:

• Vital signs when relevant
• External genitalia findings
• Speculum exam findings (cervix appearance, discharge)
• Bimanual exam findings (uterus size/position, adnexa, tenderness)
• Any procedures performed (Pap, cultures, IUD insertion)
• Lab or imaging results if available

Examples:

"Vitals: BP 118/72, HR 68. External genitalia normal, no lesions. Speculum exam: cervix nulliparous, no lesions, minimal clear discharge. Pap smear collected with spatula and cytobrush, adequate sample. Bimanual: uterus anteverted, normal size, mobile, non-tender. No adnexal masses or tenderness. No cervical motion tenderness."

"Vitals: BP 124/78, HR 82. BMI 26. External genitalia normal. Speculum exam: cervix parous, closed os, no lesions. Moderate amount of white, cottage cheese-like discharge noted. pH test 4.2. Wet mount performed in office showing budding yeast and pseudohyphae. KOH whiff test negative. Bimanual: uterus normal size, anteverted, non-tender. No adnexal masses or tenderness."

3. A - Assessment

This section is your professional clinical assessment of the patient's gynecological condition.

Purpose: Connect the subjective complaints with objective findings and provide your clinical judgment.

Key Principle: Be specific about your diagnosis or impression, even if preliminary.

What to include:

• Primary diagnosis or working diagnosis
• Any differential diagnoses considered
• Assessment of severity or risk
• Response to previous treatments if follow-up visit
• Relevant risk factors

Examples:

"38-year-old female presenting for routine well-woman examination. Last screening 3 years ago. No concerning symptoms. Physical examination normal with no abnormalities noted. Patient due for routine cervical cancer screening per guidelines. Contraception needs met with current oral contraceptive regimen."

"29-year-old female with vulvovaginal candidiasis based on clinical presentation and positive yeast on wet mount. Consistent with typical candida infection given cottage cheese-like discharge, vaginal pH 4.2, and visualization of yeast and pseudohyphae. No evidence of bacterial vaginosis or trichomoniasis. Patient has no history of recurrent infections."

4. P - Plan

This final section outlines your treatment plan and follow-up strategy.

Purpose: Establish clear next steps for treatment and monitoring.

Length: Be specific and actionable, typically 3-5 key points.

What to include:

• Treatments prescribed
• Patient education provided
• Follow-up timing and reason
• Preventive care recommendations
• When to call with concerns

Examples:

"Pap smear sent to lab, results in 7-10 days. Patient will be contacted with results. Continue current oral contraceptive regimen. Discussed breast self-awareness and recommended clinical breast exam annually. Annual well-woman exam recommended in 12 months. Patient to call with any new symptoms including abnormal bleeding, pelvic pain, or unusual discharge."

"Prescribed fluconazole 150mg, take one tablet today for vulvovaginal candidiasis. Advised to avoid douching and wear cotton underwear. Symptoms should improve within 3 days. If symptoms persist beyond 7 days, patient to call for further evaluation. Discussed that partner treatment not necessary unless symptomatic. Return to clinic if recurrent infections (more than 4 per year) for further workup."

Complete Gyn SOAP Note Examples

Now let's look at three complete examples that bring all these components together.

Example 1: Annual Well-Woman Exam

Patient: 42-year-old female
Visit Type: Preventive care
Chief Complaint: Annual gynecology check-up

S – Subjective:

Patient presents for annual well-woman examination. LMP 3 weeks ago, regular 28-30 day cycles, moderate flow lasting 5 days. No changes in menstrual pattern. Denies abnormal vaginal bleeding, pelvic pain, or unusual discharge. Currently using condoms for contraception, considering more reliable method. Sexually active with male partner in monogamous relationship for past 6 months. No dyspareunia. Last Pap smear 3 years ago was normal, HPV negative. No history of abnormal Paps. Last mammogram at age 40 was normal. Family history significant for mother with ovarian cancer diagnosed at age 58. Denies hot flashes, night sweats, or vaginal dryness. No urinary symptoms. General health good, no chronic medical conditions. Takes multivitamin daily, no other medications. Non-smoker, drinks alcohol occasionally.

O – Objective:

Vitals: BP 122/76, HR 70, Weight 148 lbs, Height 5'5", BMI 24.6
General: Well-appearing, appropriate affect
Breast Exam: No masses, skin changes, or nipple discharge bilaterally. No axillary lymphadenopathy. Breast tissue heterogeneously dense on palpation.
External Genitalia: Normal external inspection, no lesions or masses
Speculum Exam: Cervix visualized, nulliparous os, no lesions or abnormal discharge. Normal vaginal mucosa, no atrophy.
Pap Smear: Collected with spatula and cytobrush for cytology with HPV co-testing, adequate sample obtained
Bimanual Exam: Uterus anteverted, normal size, mobile, non-tender. No adnexal masses or tenderness. No cervical motion tenderness. Pelvic support normal, no prolapse.
Rectal Exam: Deferred (not clinically indicated)

A – Assessment:

42-year-old female presenting for routine gynecological care. Due for cervical cancer screening per USPSTF guidelines (last screen 3 years ago was normal). Physical examination unremarkable with no concerning findings. Patient interested in discussing contraception options. Family history of ovarian cancer in mother warrants consideration but patient currently at average risk (mother diagnosed after age 50). Breast exam normal though patient due for next mammogram at age 45 per current guidelines given average risk. Overall healthy patient with no acute gynecological concerns.

P – Plan:

Pap smear with HPV co-testing sent to laboratory, results expected in 7-10 days. Patient will be contacted with results by phone or patient portal. If both cytology and HPV testing negative, next screening in 5 years per current guidelines. Discussed contraception options including IUD, implant, and hormonal pills. Provided educational materials on each method. Patient will consider options and contact office if interested in scheduling IUD insertion or starting pills. Performed breast cancer risk assessment - patient at average risk. Recommended continuing annual clinical breast exams and mammography at age 45 (or earlier if desired). Given family history of ovarian cancer in mother, discussed ovarian cancer symptoms and signs but no genetic testing indicated at this time (mother diagnosed after age 50). Reviewed importance of pelvic floor exercises and calcium/vitamin D supplementation. Patient counseled on maintaining healthy lifestyle including regular exercise and balanced diet. Routine follow-up in 12 months for annual exam or sooner if any concerns develop. Patient instructed to call office with any new symptoms including abnormal bleeding, pelvic pain, or changes in vaginal discharge. Patient verbalized understanding of screening plan and contraception options.

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Example 2: Abnormal Vaginal Bleeding

Patient: 35-year-old female
Visit Type: Problem visit
Chief Complaint: Irregular bleeding between periods

S – Subjective:

Patient reports experiencing vaginal spotting between periods for past 2 months. Describes light pink-brown spotting occurring mid-cycle, lasting 2-3 days. LMP 1 week ago, menstrual cycles previously regular every 30 days lasting 5 days with moderate flow. No change in menstrual flow itself. Denies postcoital bleeding. Not currently sexually active, ended relationship 3 months ago. No new sexual partners. Denies pelvic pain, cramping with spotting, or foul-smelling discharge. No fever, weight loss, or other systemic symptoms. Using no contraception currently (not sexually active). Last Pap smear 18 months ago was normal. No history of STIs. No previous abnormal bleeding episodes. Denies stress but notes job change 3 months ago. Not taking any new medications or supplements. No history of thyroid disease or bleeding disorders.

O – Objective:

Vitals: BP 116/74, HR 72, Weight 136 lbs, BMI 22.8
General: Well-appearing, no acute distress
External Genitalia: Normal appearance, no lesions
Speculum Exam: Small amount of blood-tinged mucus at cervical os. Cervix appears normal, nulliparous, no visible lesions or polyps. No cervical friability. Vaginal mucosa normal.
Pap Smear: Collected for cytology given intermenstrual bleeding
Bimanual Exam: Uterus normal size, anteverted, mobile, non-tender. No adnexal masses or tenderness bilaterally. No cervical motion tenderness.
Transvaginal Ultrasound (performed in office): Uterus normal size and contour. Endometrial stripe 6mm (appropriate for cycle day). No fibroids or polyps visualized. Both ovaries normal in size and appearance with follicular activity. No adnexal masses or free fluid.
Labs Drawn: CBC, TSH, pregnancy test (urine HCG negative in office)

A – Assessment:

35-year-old nulliparous female with 2-month history of intermenstrual spotting. Differential diagnosis includes anovulatory bleeding (most likely given recent life stressor and timing), cervical pathology (less likely given normal cervical appearance but Pap sent to rule out), endometrial polyp or hyperplasia (less likely given normal ultrasound and appropriate endometrial thickness), thyroid dysfunction (TSH pending), or early pregnancy loss (ruled out with negative pregnancy test). Physical exam and ultrasound reassuring with no structural abnormalities identified. Most consistent with hormonal imbalance or anovulation given recent stress and mid-cycle timing of spotting.

P – Plan:

Pap smear sent to rule out cervical pathology, results in 7-10 days. Awaiting CBC to assess for anemia and TSH to rule out thyroid dysfunction as contributor to bleeding irregularity. Given reassuring examination and imaging, will observe for one more cycle before considering further intervention. Patient to track bleeding pattern carefully using period tracking app or calendar, noting timing, duration, and amount of spotting. Advised that stress and life changes can affect menstrual cycles and cause occasional breakthrough bleeding. Recommended lifestyle modifications including stress management, regular sleep schedule, and balanced diet. If spotting continues or worsens over next cycle, will consider trial of hormonal contraception (combined oral contraceptive) to regulate cycles even though not currently sexually active. If bleeding becomes heavy or patient develops concerning symptoms (severe pain, fever, heavy bleeding soaking through pad in 1-2 hours), instructed to contact office immediately or go to emergency department. Follow-up appointment in 6 weeks to review labs, Pap results, and bleeding pattern. Patient may call sooner if symptoms worsen or new concerns arise. Patient verbalized understanding of assessment and plan, comfortable with expectant management for now.

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Example 3: Contraceptive Counseling and IUD Insertion

Patient: 28-year-old female, G0P0
Visit Type: Procedure visit
Chief Complaint: IUD insertion for contraception

S – Subjective:

Patient presents for copper IUD insertion as discussed at previous visit 2 weeks ago. Desires highly effective, long-term contraception without hormones. LMP 5 days ago (confirmed menstrual period, not pregnant). Regular 28-day cycles. Currently using condoms with partner but desires more reliable method. Sexually active in monogamous relationship for past year. Denies history of STIs, most recent testing 6 months ago negative. No history of pelvic inflammatory disease. Never been pregnant. No current pelvic pain, abnormal bleeding, or vaginal discharge. Took ibuprofen 600mg one hour prior to appointment as instructed. Denies allergies to copper or medications. Understands IUD may cause heavier, longer periods and increased cramping. Prepared for this side effect. Has no desire for pregnancy in near future. Partner supportive of decision.

O – Objective:

Vitals: BP 118/70, HR 76
Pelvic Exam: External genitalia normal. Speculum exam reveals normal cervix, nulliparous os, no discharge. Cervix cleansed with betadine solution. Uterine sound measured 8cm depth. Tenaculum placed on anterior lip of cervix with minimal discomfort. Paragard copper IUD loaded and inserted without difficulty using insertion tube. IUD placed at fundus, strings trimmed to 3cm length. Tenaculum removed, minimal bleeding noted. Patient tolerated procedure well with moderate cramping during insertion that improved immediately after. Post-insertion speculum exam confirms strings visible at external os.
Pregnancy Test: Urine HCG negative (performed in office prior to procedure)

A – Assessment:

28-year-old nulligravid female who underwent successful Paragard copper IUD insertion for long-term contraception. Procedure performed without complications during menses to ensure non-pregnant state and ease of insertion through slightly dilated cervical os. Patient tolerated procedure well with expected temporary cramping. IUD properly positioned with strings visualized. Patient appropriate candidate for copper IUD given desire for hormone-free contraception and contraindication-free history.

P – Plan:

Copper IUD inserted successfully, effective immediately for contraception. Prescribed ibuprofen 600mg every 6 hours as needed for cramping over next 24-48 hours. Patient may use heating pad for comfort. Advised spotting and cramping normal for several days post-insertion. Discussed that periods may be heavier and longer with more cramping for first 3-6 cycles, should improve with time. Instructed patient to check for IUD strings after each period by feeling for strings at cervical opening. Demonstrated technique. If unable to feel strings or feels hard plastic of IUD, must call office and use backup contraception. Provided written instructions for IUD aftercare and warning signs. Cautioned to avoid tampons for 24 hours post-insertion. May resume normal activities and sexual intercourse after 24 hours if comfortable. Reviewed warning signs requiring immediate evaluation: severe abdominal pain, fever, heavy bleeding soaking through pad in 1 hour, foul-smelling discharge, or suspicion of pregnancy. Partner may feel strings during intercourse, which is normal. Follow-up appointment in 4-6 weeks for IUD string check and symptom assessment. Routine follow-up annually thereafter. IUD effective for 10 years. Patient to call office sooner with any concerns or questions. Patient verbalized understanding of all instructions and expressed satisfaction with procedure. No questions at this time.

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Additional Tips for Gyn SOAP Notes

Be Specific with Dates: Always document LMP and cycle regularity. This is crucial for ruling out pregnancy and understanding bleeding patterns.

Describe Findings Clearly: Instead of "normal pelvic exam," document specific findings: "cervix nulliparous, no lesions, uterus normal size and mobile, no adnexal masses."

Document Negative Findings: Especially for abnormal complaints, documenting what you don't find is as important as what you do find. "No cervical motion tenderness" or "no adnexal masses" can be clinically significant.

Include Contraception: Document current contraception method and patient satisfaction. This shows comprehensive care.

Screening Due Dates: Note when screening tests are due and whether they were performed or deferred.

Patient Education: Document what you counseled the patient about, especially for procedures or new diagnoses.

Sexual History When Relevant: Document sexual activity, number of partners, and STI risk when pertinent to the visit.

Family History for Cancer: Always note relevant family history, especially breast, ovarian, and cervical cancer.

Implementing structured SOAP notes in your gynecology practice ensures comprehensive women's health care, clear communication with other providers, and thorough documentation for medical-legal purposes.