Complete Guide to Prenatal SOAP Notes with Examples

If you've ever rushed through prenatal documentation wondering if you captured everything insurance needs, this guide will help you write clear, compliant SOAP notes.

I've talked to countless midwives, OB-GYNs, and nurse practitioners who feel the same pressure.

You're managing high-risk pregnancies, routine check-ups, and everything in between, and then there's the documentation.

Insurance companies want detailed records, but your priority is caring for expecting mothers and their babies.

That's exactly why I built SOAP Notes Doctor to streamline your documentation without sacrificing quality.

In this article, I'll show you how to write prenatal SOAP notes that meet insurance requirements and protect your practice.

🧾 What SOAP Notes Really Are (And Where They Came From)

SOAP notes might feel like a modern invention, but they've been around for decades.

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

His goal was simple: make patient documentation clear, consistent, and useful for both providers and anyone reviewing the chart later.

And that's really the spirit of SOAP notes.

They're a structured way of telling the story of what's happening with your patient.

SOAP stands for:

• S — Subjective: What the patient says (symptoms, concerns, feelings about pregnancy).
• O — Objective: What you observe (vital signs, measurements, fetal heart tones, physical findings).
• A — Assessment: Your professional interpretation (gestational age, risk factors, progress).
• P — Plan: What you're going to do next (labs, ultrasounds, follow-ups, education).

This format keeps your documentation organized, easy to read, and easy to review which is exactly why insurance companies love it.

You want to write in a way that communicates clearly and professionally.

How You Can Approach SOAP Notes

There's no one right way to write SOAP notes but there are better ways depending on your workflow.

Here are my two approaches.

1. Traditional, Manual Notes

This is pen-and-paper or free-typing every section. It works well if you like to write things out and you have time to spare. The downside is it can be slow, and sometimes you end up with notes that aren't consistent from visit to visit.

2. SOAP Notes Doctor

You record your session and add extra, rough sketchy contexts (if you need to e.g., fundal height measurement, fetal position).

The tool formats everything neatly and keeps you compliant without hours of typing.

How to Make SOAP Notes Faster

One of the biggest frustrations I hear from practitioners is how much time SOAP notes eat up after a long day.

You've just finished seeing pregnant patients all day, managing everything from morning sickness to preterm labor concerns, and instead of resting or preparing for tomorrow, you're staring at a blank screen trying to document everything in the right format.

The temptation in that moment is either to rush and leave things vague, or to overcompensate and write way too much.

Neither option is great.

The truth is, SOAP notes don't need to take forever, but they also can't be sloppy especially if you're submitting them for insurance or they become part of a medical-legal record.

Here's the trick we built:

✅ Head to soapnotes.doctor
✅ Record your session
✅ Save and generate notes automatically. right there. that same moment.
✅ Reclaim your evenings

With soapnotes.doctor, you can record a session, jot down rough texts, or even upload audio later, and the system automatically converts it into an industry-standard SOAP note.

That means you still get the clarity and compliance insurance companies want, but you don't have to type every word manually.

Maybe you have key observations you want to make?

Fundal height at 32 cm, fetal heart rate 145 bpm, trace edema in lower extremities, etc.

Use the tailorr to add them. Keep it rough. Keep it sketchy and soapnotes.doctor still does the magic regardless.

Example 1: Routine Second Trimester Visit

Patient: 28-year-old female, G2P1
Chief Complaint: Routine prenatal visit
Gestational Age: 24 weeks 3 days
Visit: Routine second trimester check

S – Subjective:

Patient reports feeling well overall. Fetal movement felt regularly, described as active. Reports occasional heartburn, especially after large meals. Denies vaginal bleeding, leaking fluid, contractions, or severe headaches. Sleep quality fair, wakes 2-3 times nightly to urinate. No significant stress reported. Prenatal vitamins taken daily.

O – Objective:

Vital signs: BP 118/72 mmHg, HR 78 bpm, weight 145 lbs (gain of 12 lbs from pre-pregnancy weight). Fundal height 24 cm, consistent with gestational age. Fetal heart rate 148 bpm via Doppler, regular rhythm. Urine dipstick negative for protein and glucose. Lower extremities show no edema. Cervix not examined per routine protocol at this gestational age.

A – Assessment:

Intrauterine pregnancy at 24 weeks 3 days with appropriate fetal growth. Normal fetal heart tones. Maternal weight gain within normal limits. No signs of gestational hypertension or preeclampsia. Low-risk pregnancy progressing normally.

P – Plan:

Continue prenatal vitamins with iron. Scheduled glucose tolerance test for 26-28 weeks to screen for gestational diabetes. Patient educated on warning signs of preterm labor and preeclampsia. Discussed nutrition and heartburn management strategies. Return visit scheduled in 4 weeks. Patient instructed to call with any concerns including decreased fetal movement, bleeding, or contractions.

Example 2: Third Trimester Visit with Elevated Blood Pressure

Patient: 32-year-old female, G1P0
Chief Complaint: Routine prenatal visit
Gestational Age: 34 weeks 2 days
Visit: Third trimester follow-up

S – Subjective:

Patient reports mild headaches over past 3 days, described as dull frontal pressure. Denies visual changes, severe epigastric pain, or sudden swelling. Fetal movement decreased slightly over last 24 hours compared to previous week, but still present. Reports swelling in feet and ankles worsening by end of day. Sleeping with 2-3 pillows due to shortness of breath when lying flat. No vaginal bleeding or fluid leakage.

O – Objective:

Vital signs: BP 142/88 mmHg (repeat 15 minutes later: 138/86 mmHg), HR 84 bpm, weight 168 lbs (gain of 4 lbs since last visit 2 weeks ago). Fundal height 33 cm, slightly less than expected for gestational age. Fetal heart rate 152 bpm via Doppler, reactive. Deep tendon reflexes 2+ bilaterally, no clonus. 2+ pitting edema bilateral lower extremities. Urine dipstick: trace protein.

A – Assessment:

Intrauterine pregnancy at 34 weeks 2 days. Elevated blood pressure concerning for gestational hypertension versus early preeclampsia. Trace proteinuria and edema noted. Fundal height slightly less than expected; fetal growth restriction cannot be ruled out. Requires close monitoring and further evaluation.

P – Plan:

Ordered comprehensive metabolic panel, complete blood count, and 24-hour urine protein collection to evaluate for preeclampsia. Scheduled growth ultrasound with biophysical profile for tomorrow to assess fetal growth and amniotic fluid levels. Non-stress test performed today showed reactive tracing. Patient educated on preeclampsia warning signs including severe headache, vision changes, right upper quadrant pain, and decreased fetal movement. Instructed to monitor blood pressure at home twice daily and keep log. Follow-up appointment scheduled in 3 days to review lab results. Patient instructed to go to labor and delivery immediately if symptoms worsen or blood pressure exceeds 140/90 mmHg at home.

Example 3: First Trimester Visit with Morning Sickness

Patient: 25-year-old female, G1P0
Chief Complaint: Nausea and vomiting, routine first prenatal visit
Gestational Age: 8 weeks 5 days by LMP
Visit: Initial prenatal visit

S – Subjective:

Patient reports nausea throughout the day, worse in morning and evening. Vomiting 3-4 times daily for past week, able to keep down small amounts of bland food and water. Reports fatigue and breast tenderness. Denies vaginal bleeding or severe abdominal cramping. Last menstrual period 8 weeks 5 days ago, regular 28-day cycles. Positive home pregnancy test 3 weeks ago. No significant medical history. Takes no medications currently. Denies tobacco, alcohol, or recreational drug use.

O – Objective:

Vital signs: BP 110/68 mmHg, HR 72 bpm, weight 132 lbs (reports 3 lb weight loss from usual weight). General appearance: appears fatigued but alert. Abdominal exam soft, non-tender, no masses. Pelvic exam: cervix closed, uterus approximately 8-week size, no adnexal masses or tenderness. Urine pregnancy test positive. Urine dipstick shows trace ketones, no protein.

A – Assessment:

Intrauterine pregnancy at approximately 8 weeks 5 days gestation by LMP, confirmed by urine pregnancy test. Nausea and vomiting of pregnancy (morning sickness) with mild dehydration evidenced by trace ketonuria and weight loss. Patient tolerating oral intake adequately at present. Low-risk first trimester pregnancy.

P – Plan:

Ordered standard first trimester labs including CBC, blood type and Rh, rubella immunity, hepatitis B surface antigen, HIV, syphilis, and urinalysis. Dating ultrasound scheduled for next week to confirm gestational age and viability. Prescribed vitamin B6 25 mg three times daily and doxylamine 12.5 mg at bedtime for nausea management. Educated on dietary modifications: small frequent meals, bland foods, adequate hydration with electrolyte drinks. Prescribed prenatal vitamins, instructed to take at bedtime with food. Discussed warning signs including severe vomiting, inability to keep down liquids, severe abdominal pain, or vaginal bleeding requiring immediate evaluation. Return visit scheduled in 4 weeks or sooner if symptoms worsen.

Why Prenatal SOAP Notes Matter for Insurance

Insurance companies scrutinize prenatal documentation more than almost any other type of medical record.

Why?

Because pregnancy involves multiple visits, potential complications, and significant liability if something goes wrong.

Clear SOAP notes show that you're:

• Monitoring maternal and fetal health appropriately
• Identifying and addressing risk factors
• Following standard of care protocols
• Educating patients on warning signs
• Documenting medical necessity for interventions

Without proper documentation, insurance may deny claims or question your clinical decisions retrospectively.

Tips for Writing Better Prenatal SOAP Notes

Here are some practical tips I've learned from working with prenatal care providers:

Be specific with measurements: Don't just write "fundal height appropriate." Write "fundal height 28 cm, consistent with 28-week gestational age."

Document fetal heart tones every visit: Include rate, rhythm, and method (Doppler, fetoscope, ultrasound).

Record vital signs consistently: Blood pressure is especially critical. Document position (sitting, left lateral) and which arm.

Note gestational age clearly: Use both weeks and days (e.g., 32 weeks 4 days) based on dating ultrasound when available.

Document patient education: Insurance wants to see you're teaching about warning signs, nutrition, and self-care.

Address no-shows and missed appointments: Document attempts to contact patient and importance of regular prenatal care.

Be thorough with risk assessment: Document smoking status, substance use, domestic violence screening, mental health, and social determinants of health.

Common Mistakes to Avoid

Vague subjective sections: "Patient feels fine" doesn't tell the story. Document specific symptoms or absence of concerning symptoms.

Skipping objective findings: Every prenatal visit should include weight, blood pressure, fundal height (after 20 weeks), and fetal heart tones.

Incomplete assessment: Don't just write "pregnancy progressing." Include gestational age, risk level, and any concerns.

Generic plans: "Continue routine care" isn't specific enough. Document what tests are due, when next visit is scheduled, and what patient should watch for.

Final Thoughts

Prenatal SOAP notes don't have to consume your evenings.

With the right system, you can create comprehensive, insurance-compliant documentation in minutes instead of hours.

Whether you're doing routine prenatal visits or managing high-risk pregnancies, clear documentation protects both you and your patients.

Try SOAP Notes Doctor and see how much time you can reclaim while maintaining the quality documentation your practice needs.

Your patients need you focused on their care, not buried in paperwork.