Quick Way to Write Trichomonas SOAP Notes for Healthcare Providers

Trichomonas SOAP Notes

It's the end of your clinic day, and you've got three charts open on your screen.

All three patients tested positive for trichomoniasis, but each situation is completely different - one is symptomatic and needs partner treatment, another was an incidental finding on a routine Pap, and the third is a test of cure visit.

You need to document each encounter properly for insurance, public health reporting, and medicolegal protection, but you're exhausted and just want to go home.

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, STI documentation was all over the place.

One provider might write "patient has discharge - treated" while another would write pages about sexual history details that probably didn't need to be in the permanent record.

There was no consistency, no structure, and definitely no standardized way to document partner notification or treatment.

Then in the late 1960s, Dr. Lawrence Weed said "we need a better system" and created the Problem-Oriented Medical Record with SOAP notes at its core.

His brilliant idea was simple: give everyone the same template so any healthcare provider could read someone else's notes and actually understand the clinical picture and treatment plan.

Here's what Dr. Weed came up with:

• S (Subjective): What the patient tells you about their symptoms and sexual health history
• O (Objective): What you observe during examination and lab results
• A (Assessment): Your clinical diagnosis and evaluation of the situation
• P (Plan): Treatment, partner notification, and follow-up strategy

This format spread quickly because it just made sense.

For trichomoniasis specifically, this structure became essential because you need to capture symptoms, sexual history, exam findings, treatment, and partner notification - all in a way that satisfies public health requirements and protects you medicolegally.

How to Write Trichomonas SOAP Notes: My Recommended Approach

When I started working with sexual health clinics and primary care providers, I noticed they'd agonize over STI documentation.

Then I learned something that simplified everything:

"Document what matters for treatment and prevention. Skip the rest."

Get the symptoms, exam findings, test results, treatment given, and partner plan documented. That's your foundation. Everything else is secondary.

I learned this from watching efficient sexual health providers work, and I built soapnotes.doctor around it.

There are technically two ways you can approach trichomonas 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, covers all the public health requirements, and most importantly, it's way faster than typing everything out.

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 the tool just captures what's necessary. Not excessive detail that could be awkward if subpoenaed, yet never misses the clinical essentials. I think that's the balance you need for STI documentation.

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. Here's how to do it efficiently without overthinking.

1. S - Subjective

This is where you capture the patient's symptoms and relevant sexual history.

This section should document what your patient tells you about their symptoms and sexual health situation.

Purpose: Document the patient's perspective on their symptoms and establish risk factors.

What to include:

• Chief complaint and symptom description
• Symptom duration and severity
• Sexual history (partners, protection use, partner symptoms)
• Last sexual contact
• Previous STI history
• Contraception method
• Last menstrual period (if applicable)

Examples:

"Patient reports 5 days of malodorous vaginal discharge described as yellow-green and frothy. Complains of vaginal itching and discomfort with urination. Sexually active with one male partner for past 6 months, inconsistent condom use. Partner has no symptoms. Last intercourse 3 days ago. No previous STI history. LMP 2 weeks ago. Currently using oral contraceptives."

"Patient here for routine annual exam, denies any vaginal symptoms, discharge, odor, or irritation. Sexually active with two partners in past 3 months, reports condom use 'most of the time.' No known STI exposures. Last tested for STIs 1 year ago, all negative. LMP 1 week ago. Using condoms for contraception."

2. O - Objective

This is where you document your examination findings and test results.

The objective section is where you record your clinical observations and laboratory data.

Purpose: Document observable findings and diagnostic test results.

What to include:

• Vital signs (if relevant)
• External genital examination findings
• Speculum examination findings
• Vaginal discharge characteristics
• Cervical appearance
• Bimanual exam findings
• Lab results (wet mount, culture, NAAT)

Examples:

"External genitalia: mild vulvar erythema, no lesions or masses. Speculum exam: copious yellow-green frothy discharge in vaginal vault, vaginal walls erythematous. Cervix with strawberry appearance (colpitis macularis), no cervical motion tenderness. Bimanual: uterus normal size, non-tender, no adnexal masses. Wet mount: numerous motile trichomonads visualized, increased WBCs, pH 6.0, positive whiff test. NAAT for trichomonas: positive."

"External genitalia: normal appearance, no lesions. Speculum exam: minimal white discharge, cervix appears normal, no erythema or friability. Bimanual: uterus anteverted, normal size, no tenderness, no adnexal masses. Pap smear collected. Routine STI screening panel sent including trichomonas NAAT. Results returned positive for trichomonas, negative for gonorrhea and chlamydia."

3. A - Assessment

This section is your clinical diagnosis and evaluation.

Purpose: Establish the diagnosis and assess any complications or comorbidities.

Key Principle: Be clear and specific about the diagnosis and its implications.

What to include:

• Primary diagnosis
• Symptom severity assessment
• Risk assessment
• Any complications or coinfections
• Partner notification needs

Examples:

"Trichomoniasis, symptomatic, confirmed by wet mount visualization of motile trichomonads and positive NAAT. Moderate symptoms with vaginal inflammation. No evidence of cervicitis or PID. Patient requires treatment and partner notification/treatment to prevent reinfection. Will test for other STIs given sexual risk factors."

"Trichomoniasis, asymptomatic, detected on routine screening. No clinical evidence of vaginal inflammation on exam. Patient requires treatment and partner notification despite lack of symptoms. Gonorrhea and chlamydia testing negative. Low-risk sexual behavior but inconsistent barrier protection warrants counseling."

4. P - Plan

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

Purpose: Document treatment, partner management, and prevention plan.

Length: Be specific about medications, partner treatment, and follow-up.

What to include:

• Antibiotic treatment prescribed
• Partner notification and treatment plan
• Counseling provided
• Other STI testing if indicated
• Follow-up instructions
• Prevention education

Examples:

"Prescribed metronidazole 2g PO single dose, taken in office under observation. Counseled to abstain from alcohol for 72 hours due to disulfiram reaction. Instructed to abstain from sexual intercourse for 7 days and until partner completes treatment. Provided expedited partner therapy (EPT) - metronidazole 2g single dose for partner with instruction sheet. Counseled on condom use to prevent future STIs. Sent additional screening for HIV, syphilis, hepatitis B and C. No test of cure needed if symptoms resolve. Patient to return if symptoms persist beyond 1 week. Reviewed prevention strategies including consistent condom use. Patient verbalized understanding of treatment plan and partner notification requirements."

"Prescribed metronidazole 500mg PO twice daily for 7 days (patient declined single-dose option due to GI concerns). Counseled on importance of completing full course and abstaining from alcohol throughout treatment and for 72 hours after last dose. Instructed to abstain from intercourse for 7 days. Provided EPT for two partners with detailed instruction sheets. Discussed importance of all partners being treated simultaneously to prevent ping-pong reinfection. Counseled on consistent condom use and offered barrier method demonstration. Routine follow-up for annual exam in 12 months unless symptoms develop. Patient to call with concerns or questions."

Complete Trichomonas SOAP Note Examples

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

Example 1: Symptomatic Trichomonas with Treatment

Patient: 26-year-old female
Visit Type: Walk-in appointment
Chief Complaint: Abnormal vaginal discharge and odor

S – Subjective:

Patient presents with complaint of abnormal vaginal discharge for past 7 days. Describes discharge as yellow-green in color, frothy texture, with strong fishy odor that is "embarrassing" at work. Reports intense vaginal itching, especially at night, rated 7/10 severity. Complains of burning with urination but denies frequency or urgency. Denies abdominal pain or fever. Sexually active with one male partner for past 4 months, uses condoms "sometimes" - estimates 50% of encounters. Last sexual intercourse 2 days ago. Partner has not reported any symptoms but patient has not specifically asked. Patient had bacterial vaginosis treated 6 months ago but no other STI history. Never tested for HIV. LMP 3 weeks ago, regular cycles. Currently not using any hormonal contraception, relies on condoms and withdrawal. Denies douching. No new soaps or products. Tried over-the-counter yeast medication 3 days ago without improvement. Denies pregnancy possibility - last pregnancy test 2 months ago was negative.

O – Objective:

Vitals: BP 118/72, HR 76, Temp 98.4°F
General: Well-appearing, no acute distress
Abdomen: Soft, non-tender, no masses, no suprapubic tenderness
External Genitalia: Mild vulvar erythema and excoriation from scratching, no ulcers, lesions, or masses, no inguinal lymphadenopathy
Speculum Exam: Copious yellow-green frothy discharge pooling in posterior fornix, diffuse vaginal wall erythema, cervix with petechial hemorrhages giving strawberry cervix appearance (colpitis macularis), no cervical motion tenderness, cervical os closed
Bimanual: Uterus anteverted, normal size, mobile, non-tender, no adnexal masses or tenderness bilaterally
Wet Mount: Numerous motile trichomonads visualized under microscope, increased polymorphonuclear leukocytes, clue cells absent, pH 6.5 (normal 3.8-4.5), positive whiff test (fishy odor with KOH)
Labs Sent: Trichomonas NAAT (confirmatory), gonorrhea/chlamydia NAAT, HIV 4th generation antibody/antigen, RPR for syphilis

A – Assessment:

26-year-old female with symptomatic trichomoniasis confirmed by wet mount visualization of motile trichomonads. Classic presentation with frothy yellow-green discharge, vaginal inflammation, and strawberry cervix appearance. Patient experiencing moderate to severe symptoms including significant pruritus and dysuria. Consistent sexual partner requires treatment for cure and prevention of reinfection. Patient at risk for other STIs given inconsistent barrier protection; additional screening indicated and sent. No evidence of upper genital tract infection (cervicitis, PID) but cervical inflammation present. Will treat presumptively today based on wet mount findings while awaiting confirmatory NAAT result.

P – Plan:

Treatment: Administered metronidazole 2g PO single dose in office (patient swallowed tablets with water, witnessed by provider). Counseled extensively on abstaining from alcohol for 72 hours due to potential disulfiram-like reaction causing severe nausea, vomiting, flushing, and headache. Provided written instructions about alcohol avoidance including avoiding mouthwash, cough syrup, or any products containing alcohol.

Partner Management: Provided expedited partner therapy (EPT) - metronidazole 2g single dose packet for partner with detailed instruction sheet explaining diagnosis, treatment, alcohol avoidance, and importance of abstinence. Counseled patient on importance of partner treatment to prevent reinfection. Discussed that partner may be asymptomatic but still carries infection.

Sexual Health Counseling: Instructed to abstain from all sexual activity (vaginal, oral, anal) for minimum 7 days and until both patient and partner have completed treatment. Educated on correct and consistent condom use; provided condoms and demonstrated proper application. Discussed that trichomoniasis increases HIV transmission risk.

Additional Testing: Sent comprehensive STI panel including HIV, syphilis, gonorrhea, and chlamydia given sexual risk factors. Results will be available in 3-5 business days; patient will be contacted by phone with results and treatment if needed.

Follow-Up: Test of cure not routinely recommended if symptoms resolve. Patient instructed to call or return if symptoms persist or worsen after 1 week. Encouraged to establish care for routine preventive gynecologic visits. Provided information about local sexual health resources and free condom programs. Reported case to local health department per public health requirements. Patient verbalized clear understanding of treatment regimen, partner notification, sexual abstinence, alcohol avoidance, and when to seek further care. Provided written discharge instructions with 24-hour nurse line number.

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Example 2: Asymptomatic Trichomonas on Routine Screening

Patient: 32-year-old female
Visit Type: Routine annual women's health exam
Chief Complaint: Annual Pap smear and check-up

S – Subjective:

Patient presents for routine annual gynecologic exam. Denies any vaginal symptoms including discharge, odor, itching, or burning. No abnormal bleeding or pelvic pain. Sexually active with one male partner (husband) in monogamous relationship for 8 years. Reports infrequent condom use within marriage. No known STI exposures, last STI screening 2 years ago was all negative. Never diagnosed with trichomoniasis or other STIs. LMP 2 weeks ago, regular 28-day cycles. Using intrauterine device (Mirena IUD) placed 3 years ago for contraception. Reports overall good health, here for Pap smear and routine labs. Denies urinary symptoms. No recent antibiotic use. No douching or vaginal product use.

O – Objective:

Vitals: BP 112/68, HR 64, BMI 23.4
General: Healthy-appearing, no distress
Abdomen: Soft, non-tender throughout
External Genitalia: Normal appearance, no lesions or discharge
Speculum Exam: Scant clear-white physiologic discharge, vaginal mucosa pink and healthy-appearing, cervix parous, no erythema or lesions, IUD strings visualized in appropriate position
Bimanual: Uterus normal size, anteverted, non-tender, no adnexal masses or tenderness
Pap Smear: Collected with spatula and cytobrush, adequate sample
STI Screening: Routine trichomonas, gonorrhea, and chlamydia NAAT collected
Pap Results (received 1 week later): NILM (negative for intraepithelial lesion or malignancy)
STI Results (received 1 week later): Trichomonas POSITIVE, gonorrhea and chlamydia NEGATIVE

A – Assessment:

32-year-old female with incidentally detected asymptomatic trichomoniasis on routine screening. Patient has no symptoms and normal pelvic examination. Despite asymptomatic presentation, treatment is indicated as patient serves as reservoir for transmission and may develop symptoms. Husband also requires treatment given marital monogamy and likelihood of shared infection. Low suspicion for other STIs given monogamous relationship and negative concurrent testing, though will discuss repeat HIV testing. Positive trichomonas result is unexpected given patient's reported monogamy; will require sensitive discussion about possible sources including duration of infection (can be asymptomatic for months to years) or undisclosed sexual contact by either partner.

P – Plan:

Patient Notification: Called patient to discuss positive trichomonas result. Explained that trichomonas is a sexually transmitted infection but can sometimes be asymptomatic for extended periods. Had sensitive discussion about infection source and importance of partner treatment. Patient was surprised but agreed to treatment and partner notification.

Treatment: Called in prescription for metronidazole 500mg tablets, take one tablet by mouth twice daily for 7 days. Provided detailed counseling via phone about abstaining from alcohol during treatment and for 72 hours after final dose. Explained common side effects including metallic taste, nausea, and dark urine.

Partner Management: Instructed patient to inform husband of diagnosis and need for treatment. Offered expedited partner therapy (EPT) - patient preferred husband make appointment for evaluation. Scheduled husband for appointment in 2 days; will provide same treatment regimen. Counseled that both partners must complete treatment before resuming intercourse.

Sexual Health Counseling: Instructed to abstain from sexual intercourse for 7 days after BOTH partners complete treatment. Acknowledged this diagnosis may raise relationship concerns; provided information for couples counseling if desired. Discussed that infection could have been present for long time before detection.

Follow-Up: Test of cure not routinely indicated for trichomonas. Patient to contact office if symptoms develop or if has concerns after discussing with husband. Encouraged open communication between partners. Return for routine annual exam in 12 months. Patient expressed understanding and agreed with treatment plan. Documented thorough counseling provided. Case reported to health department.

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Example 3: Trichomonas Test of Cure Visit

Patient: 29-year-old female
Visit Type: Follow-up appointment
Chief Complaint: Test of cure after trichomonas treatment

S – Subjective:

Patient returns for follow-up 3 weeks after treatment for trichomoniasis. Reports complete resolution of vaginal discharge, odor, and itching that brought her in initially. Denies any current vaginal symptoms. States she completed full 7-day course of metronidazole 500mg twice daily as prescribed, avoided alcohol throughout treatment and for 3 days after. Abstained from sexual activity for 10 days after starting treatment. Male partner completed treatment with same regimen (came in for evaluation and treatment 1 day after patient's initial visit). They resumed sexual intercourse 2 weeks ago and have had relations 3 times since then, using condoms each time. Partner denies any symptoms. Patient requests test of cure for "peace of mind" before discontinuing condom use in her long-term relationship. Concurrent HIV and syphilis testing from initial visit returned negative. Patient relieved but concerned about how infection was acquired given 2-year relationship with current partner.

O – Objective:

Vitals: BP 116/74, HR 68
General: Well-appearing, comfortable
External Genitalia: Normal appearance, no erythema, excoriation has healed, no lesions
Speculum Exam: Scant white discharge consistent with normal physiologic discharge, vaginal walls pink and healthy without erythema or inflammation, cervix smooth, pink, no strawberry cervix appearance noted, no discharge from os
Bimanual: Uterus normal size, anteverted, non-tender, no adnexal tenderness or masses
Wet Mount: No trichomonads visualized, normal vaginal flora, few WBCs, pH 4.5 (normal range restored), negative whiff test
Trichomonas NAAT: Sent for confirmatory test of cure per patient request

A – Assessment:

29-year-old female status post treatment for trichomoniasis, clinically cured with complete symptom resolution and normal examination. Wet mount findings consistent with successful treatment - no trichomonads visualized, normal pH restored, no inflammation. Patient and partner both completed appropriate treatment regimen and observed recommended abstinence period. Test of cure NAAT sent per patient request though not routinely indicated; wet mount already demonstrates cure. Patient has residual concerns about infection source which is appropriate to address. Relationship appears stable and both partners have completed treatment appropriately.

P – Plan:

Test Results: Explained to patient that wet mount findings demonstrate cure and test of cure NAAT is not routinely necessary for trichomoniasis when symptoms resolve. However, confirmatory NAAT sent per her request for reassurance. Results will be available in 3-5 days and patient will be called with results.

Sexual Activity: Cleared to resume sexual activity without condoms if desired since both partners completed treatment and 2 weeks have passed. Noted they have already resumed sexual activity with barriers. Encouraged continued barrier use until NAAT results return if patient prefers additional reassurance.

Prevention Counseling: Discussed that reinfection can occur with new or untreated partners. Reinforced importance of partner treatment in future if either develops symptoms. Reviewed safer sex practices and offered barrier method resupply.

Addressing Concerns: Had sensitive discussion about transmission and infection source. Explained that trichomoniasis can be asymptomatic for variable time periods (months to occasionally years), making exact timing of acquisition difficult to determine. Acknowledged this creates uncertainty about source. Encouraged open communication between partners if concerns persist. Provided information about couples counseling resources if relationship stress continues.

Routine Follow-Up: Return to routine gynecologic care. Next Pap smear due in 3 years per guidelines (recent Pap was normal). Encouraged annual STI screening given sexual activity. Patient to contact office with any new symptoms or concerns. Patient expressed relief that treatment was successful and verbalized understanding of all counseling provided. Follow-up phone call scheduled in 3 days to review NAAT results.

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Additional Tips for Trichomonas SOAP Notes

Partner Notification is Key: Always document your partner treatment plan. Expedited partner therapy (EPT) is legal in most states and should be offered when appropriate.

Document Alcohol Counseling: Metronidazole + alcohol = severe reaction. Document that you counseled about alcohol avoidance to protect yourself legally.

Sexual Abstinence: Document specific instructions about abstaining from intercourse during treatment and for 7 days after completion.

Public Health Reporting: Trichomonas is reportable in some jurisdictions. Document that case was reported if required in your area.

Sensitive Documentation: Use professional language when documenting sexual history. Avoid judgmental terminology. Remember these notes could be subpoenaed.

Test of Cure: Generally NOT recommended for trichomonas if symptoms resolve, but document if patient requests it or if symptoms persist.

Coinfection Screening: Document other STI testing offered/performed, especially HIV, given that trichomonas increases HIV transmission risk.

Pregnancy Considerations: If patient is pregnant, document gestational age and that you're using pregnancy-safe treatment regimen (metronidazole is safe after first trimester).

Implementing structured SOAP notes for trichomonas ensures comprehensive documentation, appropriate partner management, and clear treatment plans that satisfy public health requirements and provide medicolegal protection.