Complete Guide to OBGYN SOAP Note Examples for Healthcare Providers

If you've ever struggled to document OBGYN visits in a way that satisfies insurance requirements while actually being useful, this guide is for you.

I've talked to countless OBGYNs, nurse practitioners, and midwives who spend hours after their last patient trying to get their notes "just right" for insurance reviewers.

The reality is that OBGYN documentation has specific requirements that go beyond basic medical notes.

Insurance companies want to see clear clinical assessments, appropriate risk stratification, and evidence that care is medically necessary.

That's exactly why I built SOAP Notes Doctor to handle the heavy lifting of documentation while you focus on patient care.

In this article, I'll show you exactly how to write OBGYN SOAP notes that meet insurance standards, with real examples you can use as templates.

🧾 What SOAP Notes Really Are (And Why They Matter for OBGYN)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose.

They were introduced in the 1960s by Dr. Lawrence Weed as part of the Problem-Oriented Medical Record (POMR).

His goal was straightforward: create a documentation system that anyone reviewing a chart could understand quickly and completely.

For OBGYN specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of pregnancy progression or gynecological conditions
• Appropriate risk assessment and management
• Medical necessity for procedures and interventions
• Continuity of care across multiple visits

SOAP stands for:

• S — Subjective: What the patient reports about symptoms, concerns, pregnancy progress, or gynecological issues.
• O — Objective: Your clinical findings including vitals, physical exam results, fetal measurements, lab results, and ultrasound findings.
• A — Assessment: Your clinical diagnosis, risk assessment, gestational age determination, and evaluation of patient's condition.
• P — Plan: Your treatment plan including medications, follow-up testing, patient education, delivery planning, and next appointment.

This structure keeps your documentation organized, defensible, and insurance-friendly.

You're not just recording what happened you're building a clinical narrative that justifies ongoing care and interventions.

How You Can Approach OBGYN SOAP Notes

There's no single correct method for writing OBGYN SOAP notes, but some approaches work better than others depending on your practice.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: typing out each section after each visit. It works if you have strong clinical writing skills and consistent time built into your schedule. The challenge is it's time-consuming, and notes can become inconsistent across different providers or shifts in hospital settings.

2. SOAP Notes Doctor

You record your examination findings or dictate your observations, and the tool automatically structures everything into proper SOAP format. It maintains consistency, saves hours of documentation time, and ensures you never miss critical components that insurance companies look for.

How to Make OBGYN SOAP Notes Faster

One of the biggest complaints I hear from OBGYN providers is how documentation eats into their already limited time.

You've just finished a full day of prenatal visits, procedures, and maybe an emergency delivery, and instead of going home to rest, you're stuck typing detailed notes for insurance.

The pressure is real: make them too brief and you risk denials or liability issues; make them too detailed and you've just added hours to your day.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your examination findings or dictate key observations
✅ Generate properly formatted SOAP notes instantly
✅ Get your evenings and weekends back

With soapnotes.doctor, you can record during or right after a visit, add rough notes about specific findings, or even upload audio later. The system converts everything into insurance-compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness that insurance companies require, but without manually typing every detail.

Maybe you noted specific findings?

Fundal height measuring 32cm, fetal heart rate 145bpm, trace edema bilateral ankles, patient reports decreased fetal movement yesterday but normal today.

Use the tailorr feature to add them. Keep it raw and unpolished soapnotes.doctor handles the rest.

Example 1: Routine Prenatal Visit, Third Trimester

Patient: 29-year-old G2P1 female
Gestational Age: 32 weeks 4 days by LMP, consistent with dating ultrasound
Chief Complaint: Routine prenatal care, reports mild ankle swelling
Visit: Prenatal check-up

S – Subjective:

Patient reports feeling well overall. Fetal movement active and regular, averaging 10-12 movements per 2-hour period. Reports mild bilateral ankle swelling by end of day that resolves with elevation overnight. Denies headaches, visual changes, epigastric pain, or vaginal bleeding. Some lower back discomfort that improves with rest. Sleeping 6-7 hours nightly with 2-3 bathroom trips. Bowel movements regular. Denies contractions. Completed glucose tolerance test last week. Taking prenatal vitamins daily. No new medications or supplements.

O – Objective:

Vital Signs: BP 118/74 (baseline 110/68), HR 82, Wt 156 lbs (pre-pregnancy 135 lbs, total gain 21 lbs), Temperature 98.4°F
General: Alert, well-appearing, in no acute distress
Abdomen: Gravid, fundal height 32cm (appropriate for gestational age), no tenderness, Leopold maneuvers indicate vertex presentation
Extremities: Trace bilateral ankle edema, no calf tenderness, negative Homan's sign, DTRs 2+ and symmetric
FHR: 145 bpm by Doppler, regular rhythm, reassuring
Cervix: Deferred (not indicated at this gestational age)
Urinalysis: Negative for protein, glucose, leukocytes, nitrites
Lab Results: 1-hour glucose challenge test 128 mg/dL (normal, less than 140), Hgb 11.8 g/dL

A – Assessment:

Intrauterine pregnancy at 32 weeks 4 days, appropriate size for dates. Single viable intrauterine gestation, vertex presentation. Physiologic edema of pregnancy, mild. Blood pressure within normal limits with slight elevation from baseline, no signs of preeclampsia. Glucose tolerance test normal, gestational diabetes ruled out. Mild anemia of pregnancy, hemoglobin adequate. Low-risk pregnancy progressing normally.

P – Plan:

Continue routine prenatal care. Patient to continue prenatal vitamins with iron supplementation. Discussed normal physiologic changes of third trimester including edema management through elevation, left lateral positioning, and adequate hydration. Reviewed warning signs requiring immediate evaluation: severe headache, visual changes, upper abdominal pain, decreased fetal movement, vaginal bleeding, regular contractions, or rupture of membranes. Patient verbalized understanding. Scheduled for Group B Strep screening at 36 weeks. Begin weekly prenatal visits starting at 36 weeks. Discussed birth plan preferences and hospital pre-registration. Encouraged continued physical activity as tolerated. Follow-up in 2 weeks for routine prenatal visit with fundal height assessment and fetal heart rate check. Patient to call with any concerns or questions before next scheduled visit.

Example 2: Annual Gynecological Exam with Abnormal Pap History

Patient: 35-year-old female
Chief Complaint: Annual well-woman exam, follow-up for previous ASCUS Pap result
Visit: Preventive care visit

S – Subjective:

Patient presents for annual gynecological examination. Last Pap smear 18 months ago showed ASCUS (atypical squamous cells of undetermined significance), HPV testing positive for high-risk type. Patient completed colposcopy with Dr. Smith 12 months ago showing CIN 1, managed conservatively with repeat Pap scheduled for today. Reports regular menstrual cycles every 28-30 days, lasting 4-5 days, moderate flow. Currently using oral contraceptive pills (OCPs) for past 3 years with good tolerance. Denies intermenstrual bleeding, postcoital bleeding, or abnormal discharge. Sexually active in monogamous relationship, no history of STIs. Denies pelvic pain or dyspareunia. Last mammogram at age 35 was normal. Family history significant for mother with breast cancer at age 58. No tobacco use, occasional alcohol. Denies vaginal dryness or urinary symptoms.

O – Objective:

Vital Signs: BP 122/78, HR 72, BMI 24.3
General: Well-appearing, appropriate affect
Breast Exam: No masses, dimpling, or nipple discharge bilaterally; no axillary lymphadenopathy
External Genitalia: Normal external inspection, no lesions
Speculum Exam: Cervix visualized, nulliparous os, no visible lesions, no discharge
Bimanual Exam: Uterus anteverted, normal size, mobile, non-tender; no adnexal masses or tenderness; no cervical motion tenderness
Pap Smear: Collected with spatula and cytobrush, adequate sample obtained, sent for cytology with reflex HPV testing
Screening: Patient declined STI testing (monogamous, asymptomatic)

A – Assessment:

Patient presenting for routine gynecological care with history of ASCUS/HPV+ and CIN 1. Due for surveillance Pap smear per ASCCP guidelines. Current cervical appearance unremarkable on visual inspection. Low-grade cervical dysplasia, stable, under appropriate surveillance. Contraception needs met with OCPs. Family history of breast cancer warrants continued screening vigilance but patient is adhering to recommended screening schedule.

P – Plan:

Pap smear with HPV co-testing sent to lab, results expected in 7-10 days. Patient will be contacted with results and follow-up plan based on cytology findings. If Pap negative/HPV negative, can return to routine 3-year screening intervals per guidelines. If remains ASCUS or shows progression, will schedule repeat colposcopy. Continue current oral contraceptive regimen. Performed breast cancer risk assessment, patient at slightly elevated risk due to family history. Recommended continuing annual clinical breast exams and mammography beginning at age 40 (or earlier if desired given family history). Discussed importance of HPV vaccination for any future children. Provided patient education on cervical cancer screening, HPV persistence, and lifestyle factors that support immune clearance. Patient verbalized understanding of surveillance plan. Return to clinic in 1 year for annual exam or sooner if results warrant intervention. Patient instructed to call with any new symptoms including abnormal bleeding, pelvic pain, or changes in vaginal discharge.

Example 3: First Trimester Visit with Nausea and Vomiting

Patient: 26-year-old G1P0 female
Gestational Age: 8 weeks 2 days by LMP
Chief Complaint: First prenatal visit, severe nausea and vomiting
Visit: Initial OB visit

S – Subjective:

Patient presents for first prenatal visit. LMP 8 weeks 2 days ago, regular 28-day cycles, positive home pregnancy test 4 weeks ago. This is a planned, desired pregnancy. Reports severe nausea throughout day, worse in morning and evening, with vomiting 4-6 times daily for past 2 weeks. Has been unable to keep down most solid foods, tolerating small amounts of crackers, ginger ale, and water. Lost 5 lbs since conception. Denies fever, abdominal pain, or diarrhea. Fatigue significant. Denies vaginal bleeding or cramping. Tried vitamin B6 25mg three times daily without significant relief. Started prenatal vitamins but discontinued 1 week ago due to worsening nausea. Denies current medication use except prenatal vitamins (discontinued). No known drug allergies. No history of STIs. Partner supportive. Denies tobacco, alcohol, or drug use. Works as an elementary school teacher, has missed 3 days of work in past week due to nausea.

O – Objective:

Vital Signs: BP 108/68, HR 88, Wt 128 lbs (pre-pregnancy 133 lbs, 5 lb loss), Temperature 98.2°F
General: Appears fatigued but alert, mildly dehydrated appearance
HEENT: Mucous membranes slightly dry, no scleral icterus
Abdomen: Soft, non-distended, no tenderness, no palpable masses
Pelvic Exam: External genitalia normal, speculum exam reveals closed cervical os with no bleeding, bimanual exam shows normal-sized anteverted uterus appropriate for dates, no adnexal masses or tenderness
Labs Ordered: Comprehensive metabolic panel, CBC, blood type and Rh, antibody screen, rubella immunity, hepatitis B surface antigen, HIV, syphilis (RPR), TSH, urinalysis with culture
Urinalysis (in-office): Specific gravity 1.028 (concentrated), ketones 2+, negative protein, negative blood, negative nitrites/leukocytes
Transvaginal Ultrasound: Single intrauterine gestation visualized, crown-rump length 16mm (consistent with 8 weeks 1 day), fetal cardiac activity present at 167 bpm, no adnexal masses, no free fluid

A – Assessment:

Intrauterine pregnancy at 8 weeks 2 days, viable, appropriate size for dates, confirmed by ultrasound. Nausea and vomiting of pregnancy (morning sickness), moderate to severe. Mild dehydration evidenced by weight loss, concentrated urine, and ketonuria. No signs of hyperemesis gravidarum requiring hospitalization at this time but patient approaching this threshold. Risk factors for progression include primigravida status and severity of current symptoms.

P – Plan:

Nausea Management: Prescribed ondansetron 4mg tablet, take every 8 hours as needed for nausea, max 3 tablets daily. Prescribed doxylamine 25mg with pyridoxine 25mg (combination therapy), take one tablet at bedtime. If insufficient relief in 48 hours, increase to morning dose as well. Provided dietary counseling: eat small, frequent meals every 2-3 hours; focus on bland, high-protein foods; avoid empty stomach; keep crackers at bedside. Encouraged continued vitamin B6 supplementation separate from prenatal vitamin.

Hydration: Instructed to increase fluid intake, goal 2 liters daily, taking small frequent sips. If vomiting continues and unable to maintain hydration, patient to return to clinic or go to urgent care for IV fluids.

Prenatal Care: Prescribed prenatal vitamin with lower iron content (may reduce nausea), take with food in evening. Reviewed first trimester warning signs: vaginal bleeding, severe abdominal pain, fever, signs of dehydration. Reviewed dietary restrictions in pregnancy including avoiding raw fish, deli meats, soft cheeses, alcohol. Discussed early pregnancy precautions and activity modifications.

Labs: Comprehensive lab panel sent, results will be reviewed at next visit or patient called if any abnormalities requiring intervention.

Follow-up: Return to clinic in 2 weeks for nausea reassessment and initial prenatal lab review. If symptoms worsen, weight loss continues, or unable to keep down fluids, patient to contact office immediately for evaluation. Scheduled for nuchal translucency screening ultrasound at 12 weeks if desired (patient will consider). Patient provided with after-hours contact number and instructed on when to seek emergency care. Patient verbalized understanding of treatment plan and warning signs.

Example 4: Postpartum Visit, 6 Weeks After Delivery

Patient: 32-year-old G3P3 female
Delivery: 6 weeks ago, spontaneous vaginal delivery at 39 weeks 2 days
Chief Complaint: Routine postpartum check
Visit: Postpartum follow-up

S – Subjective:

Patient presents for routine 6-week postpartum examination following uncomplicated vaginal delivery of healthy female infant, birth weight 7 lbs 4 oz. Reports lochia has resolved, no longer bleeding. Breastfeeding exclusively, infant latching well, no nipple pain or concerns. Milk supply adequate. Reports some perineal discomfort for first 2 weeks but now resolved (had second-degree laceration repaired at delivery). Currently using barrier contraception (condoms), desires long-term contraception discussion. Denies postpartum depression symptoms on screening questions, reports good family support and adjusting well to infant care. Sleep fragmented due to nighttime feedings but feels rested overall. Reports some urinary frequency and nocturia but attributes to increased fluid intake for breastfeeding. Denies urinary incontinence. Bowel movements regular, no constipation. Has not resumed sexual activity yet. No current medications except prenatal vitamins.

O – Objective:

Vital Signs: BP 116/72, HR 76, Wt 142 lbs (pre-pregnancy 135 lbs, delivery weight 168 lbs)
General: Alert, well-appearing, positive affect, appropriate interaction
Breast Exam: Breasts soft, no masses, no erythema, no tenderness, nipples intact without fissures
Abdomen: Soft, non-tender, uterus non-palpable, well-healed cesarean scar if applicable (N/A for this patient), diastasis recti approximately 2cm
Pelvic Exam: External genitalia normal healing, perineal laceration well-healed without breakdown or granulation tissue, speculum exam reveals cervix closed, no discharge, bimanual exam shows uterus normal size, anteverted, non-tender, no adnexal masses
Edinburgh Postnatal Depression Scale: Score 4 (normal, less than 10)

A – Assessment:

Postpartum day 42 status post uncomplicated spontaneous vaginal delivery with second-degree laceration. Normal postpartum recovery, all healing appropriate. Successful establishment of breastfeeding. No signs or symptoms of postpartum depression or anxiety. Patient desires contraception.

P – Plan:

Contraception Counseling: Discussed contraceptive options compatible with breastfeeding including progestin-only pill, IUD (copper or hormonal), implant, and barrier methods. Patient interested in progestin-only pill for convenience and plans to transition to IUD after weaning. Prescribed norethindrone 0.35mg (progestin-only pill), emphasized importance of taking same time daily for efficacy, especially while breastfeeding. Reviewed that this will not affect milk supply. Patient verbalized understanding.

Postpartum Recovery: Cleared for all activities including exercise and sexual intercourse when comfortable. Encouraged pelvic floor exercises (Kegels) to address diastasis recti and support pelvic floor recovery. Discussed gradual return to exercise, listening to body signals.

Breastfeeding Support: Encouraged continued exclusive breastfeeding for 6 months if possible. Provided lactation consultant contact information for any future concerns.

Mental Health: Reviewed postpartum depression warning signs including persistent sadness, anxiety, difficulty bonding with infant, intrusive thoughts. Patient to contact office immediately if experiences any concerning symptoms. Reinforced importance of self-care and accepting help from support system.

Preventive Care: Patient due for Pap smear, can schedule in 3-6 months. Up to date on mammography (not yet indicated by age). Recommended flu vaccine when available if not received during pregnancy.

Follow-up: No further OB follow-up needed unless concerns arise. Return to routine gynecological care for annual exams. Patient instructed to contact office with any concerns including abnormal bleeding, fever, breast concerns, or mood changes. Congratulated patient on healthy delivery and recovery.

Key Components Insurance Companies Look For in OBGYN SOAP Notes

When reviewing your OBGYN documentation, insurance companies specifically want to see:

1. Clear Risk Stratification

Identify whether pregnancy is low-risk or high-risk. Document risk factors including maternal age, BMI, previous pregnancy complications, chronic conditions, or concerning findings.

2. Appropriate Screening and Testing

Document that you're following standard prenatal care guidelines: glucose screening, Group B Strep testing, genetic screening offered, Rh status, infectious disease screening.

3. Gestational Age Documentation

Always include gestational age by LMP and confirm with dating ultrasound. Document when measurements are appropriate or concerning for dates.

4. Vital Signs and Growth Parameters

Weight gain, blood pressure trends, fundal height measurements, and fetal growth all demonstrate appropriate monitoring.

5. Patient Education

Document counseling provided on warning signs, lifestyle modifications, birth planning, contraception, or any procedures performed.

6. Follow-up Plans

Clear documentation of next appointment timing, what will be done at next visit, and circumstances requiring earlier contact.

Common Mistakes to Avoid

Inadequate Risk Assessment: Document specific risk factors rather than just labeling "high-risk" without explanation.

Missing Gestational Age: Every prenatal note should include current gestational age.

Vague Symptom Documentation: Instead of "patient feels fine," document specific symptom screening: denies bleeding, denies contractions, fetal movement normal.

Forgetting Vital Signs: Blood pressure, weight, and fetal heart rate should be in every prenatal note.

Skipping Patient Education: Insurance wants to see you're counseling patients, not just examining them.

No Comparison to Previous Visits: Show trends in blood pressure, weight gain, fundal height, or symptom progression.

Final Thoughts

OBGYN SOAP notes don't need to be overwhelming.

They need to be thorough, yes, but they don't need to consume your life.

The key is having a system that captures the right information without making you feel like a secretary instead of a clinician.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that serves your patient and satisfies insurance requirements.

Your time is better spent caring for patients than fighting with documentation.

That's exactly why we built this tool.

Try it out, see how much time you get back, and let me know what you think.

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