Complete Guide to Prenatal SOAP Note Examples for Healthcare Professionals

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

I've talked to countless OB-GYNs, midwives, and prenatal care providers who spend hours after their last appointment trying to get their notes "just right" for insurance reviewers.

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

Insurance companies want to see appropriate monitoring of maternal and fetal health, clear risk assessments, and evidence that care meets standard prenatal guidelines.

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 prenatal SOAP notes that meet insurance standards, with real examples you can use as templates.

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

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 prenatal care specifically, SOAP notes are critical because they demonstrate:

• Appropriate monitoring of pregnancy progression
• Risk factor identification and management
• Adherence to prenatal care guidelines
• Medical necessity for interventions or additional visits
• Continuity of care across trimesters

SOAP stands for:

• S — Subjective: What the patient reports about symptoms, concerns, fetal movement, and overall well-being.
• O — Objective: What you observe and measure during the visit, including vital signs, fundal height, fetal heart tones, and exam findings.
• A — Assessment: Your clinical interpretation, including gestational age, pregnancy progression, risk assessment, and any complications.
• P — Plan: Your care plan going forward, including tests, interventions, education, follow-up timing, and delivery planning.

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

You're not just recording what happened you're building a clinical narrative that demonstrates appropriate prenatal care.

How You Can Approach Prenatal SOAP Notes

There's no single correct method for writing prenatal 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 visits or providers in group practices.

2. SOAP Notes Doctor

You record your visit 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 Prenatal SOAP Notes Faster

One of the biggest complaints I hear from prenatal care providers is how documentation eats into their personal time.

You've just finished back-to-back prenatal visits with varying levels of complexity, and instead of reviewing labs or preparing for deliveries, you're stuck typing detailed notes for insurance.

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

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your visit 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 measured specific findings?

Fundal height 28cm, FHR 148 bpm, trace edema bilateral ankles, patient reports decreased fetal movement yesterday but normal today, discussed warning signs.

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

Example 1: First Trimester Prenatal Visit

Patient: 28-year-old G2P1001
Chief Complaint: Initial prenatal visit
Gestational Age: 8 weeks 4 days by LMP
EDD: August 15, 2026

S – Subjective:

Patient reports LMP of June 10, 2025, with regular 28-day cycles. Home pregnancy test positive 2 weeks ago. Experiencing mild nausea, particularly in mornings, without vomiting. Denies vaginal bleeding or cramping. Reports increased urinary frequency and breast tenderness. Fatigue significantly increased compared to baseline. Denies use of tobacco, alcohol, or recreational drugs. Previous pregnancy uncomplicated, spontaneous vaginal delivery at 39 weeks, infant weight 7 lbs 3 oz. Currently taking prenatal vitamins started 1 week ago. No known medication allergies. Partner supportive, planned pregnancy.

O – Objective:

Vital signs: BP 118/72, HR 76, Wt 142 lbs (baseline pre-pregnancy weight 140 lbs), Temp 98.4°F. General appearance: well-nourished, no acute distress. Thyroid: no enlargement. Cardiovascular: RRR, no murmurs. Lungs: clear to auscultation bilaterally. Abdomen: soft, non-tender, no masses. Pelvic exam: cervix closed, no lesions, uterus approximately 8-week size, no adnexal masses or tenderness. Transvaginal ultrasound performed: single intrauterine pregnancy with fetal cardiac activity 167 bpm, CRL 16mm consistent with 8 weeks 3 days gestation. No free fluid in cul-de-sac.

A – Assessment:

Intrauterine pregnancy at 8 weeks 4 days gestation, EDD August 15, 2026, dating by LMP confirmed by ultrasound. G2P1001, low-risk pregnancy at present. Normal first trimester presentation with typical early pregnancy symptoms.

P – Plan:

Prenatal labs ordered: CBC, blood type and Rh, antibody screen, RPR, HIV, hepatitis B surface antigen, rubella immunity, urine culture, TSH. Genetic screening discussed; patient declined NIPT, will consider quad screen at appropriate gestational age. Prescribed prenatal vitamins with DHA. Provided first trimester education including nutrition, exercise, warning signs (bleeding, severe cramping, severe vomiting), and teratogen avoidance. Discussed normal first trimester symptoms and management strategies for nausea (small frequent meals, ginger, vitamin B6). Patient verbalized understanding. Follow-up visit scheduled in 4 weeks at approximately 12 weeks gestation. Instructed to call with any concerns or warning signs before scheduled visit.

Example 2: Second Trimester Routine Visit

Patient: 32-year-old G1P0
Chief Complaint: Routine prenatal visit
Gestational Age: 24 weeks 2 days
EDD: March 22, 2026

S – Subjective:

Patient reports feeling well overall. Fetal movement felt regularly, approximately 10 movements per day, described as "rolling and kicking." Denies contractions, vaginal bleeding, or leakage of fluid. Reports occasional heartburn, managed with dietary modifications and occasional antacids. Sleep becoming more difficult due to discomfort finding comfortable position. Denies headaches, visual changes, or significant swelling. No urinary symptoms. Continues working full-time as accountant, tolerating well. Diet adequate, taking prenatal vitamins daily. Partner attending prenatal classes with patient.

O – Objective:

Vital signs: BP 122/78 (baseline 118/72), HR 82, Wt 156 lbs (weight gain 14 lbs from pre-pregnancy, appropriate for gestational age). Urine dipstick: trace protein, negative glucose, negative leukocytes, negative nitrites. Fundal height: 24 cm, appropriate for dates. Fetal heart rate: 142 bpm, regular, heard via Doppler. Leopold's maneuvers: fetus in cephalic presentation. Extremities: no edema, no calf tenderness. Reflexes: 2+ and symmetric. Cervix: not examined (no indication).

Anatomy ultrasound from 1 week ago reviewed: all fetal structures visualized and appear normal, estimated fetal weight 50th percentile, amniotic fluid index normal, placenta anterior and fundal with no previa, cervical length 38mm.

Glucose challenge test results from 2 days ago: 118 mg/dL (normal, below 140 mg/dL threshold).

A – Assessment:

Intrauterine pregnancy at 24 weeks 2 days, appropriate for gestational age. G1P0, low-risk pregnancy with normal anatomy scan and glucose screening. Blood pressure slightly elevated from baseline but within normal limits, will monitor. Appropriate weight gain and fetal growth. No complications identified.

P – Plan:

Continue routine prenatal care. Discussed warning signs of preterm labor (regular contractions, pelvic pressure, low back pain, watery discharge) given gestational age entering viability period. Reviewed signs of preeclampsia (severe headache, visual changes, right upper quadrant pain, significant swelling). Instructed on fetal kick counts beginning at 28 weeks. Provided education on third trimester symptoms to expect. Recommended sleeping on left side to optimize placental blood flow. Heartburn management reviewed; may use calcium carbonate antacids as needed. Next visit scheduled in 4 weeks at 28 weeks for routine check and to discuss birth preferences. RhoGAM to be administered at 28 weeks visit (patient is Rh negative, partner Rh positive, antibody screen negative). Patient encouraged to continue current activity level and prenatal vitamins. Instructed to call with any concerns before scheduled visit.

Example 3: Third Trimester Visit with Complications

Patient: 35-year-old G3P2002
Chief Complaint: Routine visit, reports increased swelling
Gestational Age: 34 weeks 5 days
EDD: January 28, 2026

S – Subjective:

Patient reports significant increase in swelling of hands, feet, and face over past 3 days. States her rings no longer fit and shoes feel tight. Denies headache today but had "bad headache" yesterday that resolved with acetaminophen. No visual changes, no right upper quadrant or epigastric pain. Fetal movement somewhat decreased yesterday but "normal" today, approximately 8-10 movements per 2-hour period this morning. No contractions, no vaginal bleeding or leakage. Sleep poor due to discomfort and frequent urination. Some shortness of breath with exertion, attributed to "baby pushing on lungs." Patient anxious about early delivery given history of preterm birth with second pregnancy (delivered at 35 weeks due to preeclampsia).

O – Objective:

Vital signs: BP 148/92 (repeat in 15 minutes: 146/94; baseline throughout pregnancy 118-124/70-78), HR 88, Wt 178 lbs (gained 6 lbs in 2 weeks; total weight gain 32 lbs from pre-pregnancy weight 146 lbs). Patient appears uncomfortable but not in acute distress. Urine dipstick: 2+ protein (no protein at previous visit). Fundal height: 33 cm, slightly small for dates. Fetal heart rate: 152 bpm, reactive, no decelerations. NST performed: reactive with two accelerations in 20 minutes. Leopold's maneuvers: cephalic presentation, vertex. Extremities: 2+ pitting edema bilateral lower extremities to mid-shin, 1+ edema bilateral hands, facial edema noted. Deep tendon reflexes: 3+ with 2 beats of clonus at ankles. Cervix: not examined given elevated blood pressure.

A – Assessment:

Intrauterine pregnancy at 34 weeks 5 days gestation. G3P2002, advanced maternal age. Gestational hypertension vs. preeclampsia with severe features. New-onset hypertension (BP persistently ≥140/90), new proteinuria, significant edema, hyperreflexia with clonus, recent headache, and rapid weight gain concerning for preeclampsia. Patient at increased risk given history of preeclampsia in previous pregnancy and current presentation. Fundal height slightly below expected may indicate growth restriction, requires further evaluation.

P – Plan:

Stat labs ordered: complete metabolic panel (evaluate liver enzymes, creatinine, platelet count), CBC, 24-hour urine for protein and creatinine clearance (patient given collection instructions). Obstetric ultrasound ordered today for biophysical profile, amniotic fluid assessment, and estimated fetal weight to evaluate for intrauterine growth restriction. Patient advised she may require admission depending on lab results and ultrasound findings. Contacted on-call physician regarding patient's presentation. Provided extensive counseling on warning signs requiring immediate presentation to labor and delivery: severe headache unrelieved by acetaminophen, visual changes (blurred vision, seeing spots), right upper quadrant or epigastric pain, decreased fetal movement, contractions, bleeding, or rupture of membranes. Blood pressure management discussed; if lab work and ultrasound concerning, patient will be admitted for further monitoring and possible delivery. Betamethasone administration discussed for fetal lung maturity if delivery anticipated. Magnesium sulfate for seizure prophylaxis discussed if admitted. Patient verbalized understanding of seriousness of condition and plan. Partner present and supportive. Patient will await lab and ultrasound results in office. If discharged home today, strict instructions for modified bed rest, left lateral position, high-protein diet, and return visit in 48 hours. However, admission for close monitoring likely given severity of presentation.

Key Components Insurance Companies Look For in Prenatal SOAP Notes

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

1. Gestational Age Documentation

Always document gestational age and EDD in each note. Insurance tracks that visits align with standard prenatal care schedules.

2. Appropriate Risk Assessment

Document risk factors: maternal age, BMI, previous pregnancy complications, chronic conditions, smoking, medications. Update risk status as pregnancy progresses.

3. Standard Measurements and Monitoring

Include vital signs (especially blood pressure), weight gain, fundal height after 20 weeks, and fetal heart tones at every visit. Missing these raises red flags.

4. Evidence of Patient Education

Document discussions about warning signs, nutrition, preparation for delivery, breastfeeding intentions. This demonstrates comprehensive care.

5. Complication Management

When complications arise, document severity, interventions, and medical necessity for increased monitoring or early delivery.

6. Lab and Test Results

Reference when labs were ordered, when results reviewed, and how they influenced management. Don't just note "labs pending."

7. Follow-up Plans

Specify when the next visit should occur and why. Earlier than routine follow-up requires justification.

Common Mistakes to Avoid

Inconsistent Gestational Age Dating: Use consistent dating method throughout pregnancy. Switching between LMP and ultrasound dating causes confusion.

Missing Vital Signs: Blood pressure and weight are non-negotiable at every prenatal visit. Fetal heart tones after 10-12 weeks.

Vague Patient Education: "Discussed warning signs" isn't enough. Specify what you discussed.

Inadequate Risk Documentation: If patient has risk factors, document them. They justify additional testing and visits.

Not Documenting Patient Compliance: If patient missed visits or declined recommended testing, document it with patient's stated reason.

Copy-Pasting Without Updates: Insurance reviewers notice when week 28 notes are identical to week 32. Each visit should reflect that specific appointment.

Ignoring Red Flags: If something seems off (blood pressure creeping up, poor weight gain, patient anxiety), document it even if not diagnostic yet. It shows vigilant monitoring.

Final Thoughts

Prenatal 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 healthcare provider.

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 mothers and babies 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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