How to Write a SOAP Note With Obstetric Examples
Why We Write SOAP Notes
Proper charting is an incredibly important form of communication among healthcare professionals. Healthcare providers need to be fluent in this form of charting. This article will break down the basics of how to write a SOAP note with obstetric examples.
S: Subjective Data
O: Objective Data
A: Assessment (Diagnosis)
Subjective data is what the patient tells you. Here are examples of what comes after Subjective data:
- Demographics: age, sex
- Chief complaint: Why are they here? Use their words
- History of Present Illness: all medical information relevant to today's particular complaint.
- OB/GYN Hx: If female, any pregnancy history (Gravida/Para).
- Past medical/surgical history: i.e. Hypertension, Diabetes, Wisdom teeth extraction, foot surgery, etc.
- Family history: Family medical history- interview about mom, dad, siblings, and grandparents on both sides. Any notable history such as hypertension, cancer, stroke, cardiac disease, diabetes should be included.
- Social history: Alcohol, tobacco use, recreational drug use, seatbelt safety, guns, domestic history, mental health history.
Data that the health provider can directly observe:
General appearance: Is patient alert and oriented? Is patient in distress? Does patient appear healthy or well-nourished?
Vital signs: blood pressure, pulse, respirations, temperature, height, weight.
Physical exam findings:
- Head, Ears, Ears, Nose, Throat (HEENT): Is the head normocephalic? Are there any issues with sinuses? What does the tympanic membrane look like in the ear? Is there any discharge from the ears, eyes, or nose? Describe it. What do the mucous membranes look like of the mouth, nose, and throat? Are the nares patent? Is there exudate or swelling from the tonsils?
- Neck: Describe ROM, skin, thyroid.
- Heart: Describe the rate and rhythm. Is there any murmurs or additional heart sounds? Capillary refill? Bruits?
- Lungs: Are there any crackles or wheezes? Are they clear to auscultation?
- Abdomen: Is it soft? Is it tender? Is it distended? Can you hear bowel sounds in all four quadrants? Describe inguinal area.
- Musculoskeletal: Is the spine aligned? ROM of spine? Is there erythema or tenderness? Tenderness? Muscular development? Gait?
- Back: Examine the spine. Gait? Posture? Spinal deformity? Symmetry of spinal muscles? Muscle spasms? CVA tenderness?
- Extremities: Think of both upper and lower. Are there any deformities or joint abnormalities? Are the pulses in tact? ROM? Are there any varicosities? Is there any cyanosis, clubbing, or edema? Describe reflexes.
- Neurologic: Are there any neurologic issues? HA? Visual disturbances like blurred vision, floaters, or light disturbances?
- Skin: Is it warm or cool to touch? Moist or dry? Describe any rash or tenderness.
- Fetus: Is the patient pregnant? Bimanual exam results? Fetal heart tone range? Is there fetal movement? What is the EDD or estimated gestational age?
Labs: Results of any labs that are relevant and available today (Urinalysis, blood sugar, labs available from prior visit).
Assessment means diagnosis. Under assessment, include:
- Differential diagnosis
What will you do to treat the diagnosis?
- Medications prescribed
- Diagnostics ordered: labs, ultrasound, radiology
- Therapeutic: diet, activity
- Patient education provided
- Referrals: specialties, therapies, other services
- Disposition: Discharge home, continue monitoring, transfer units.
Example New OB SOAP note
New Antepartum Visit
Demographics: 19 yo G1P1000 @ 10w2d by irregular periods and unsure LMP
CC: Unintended pregnancy, pt is accepting but overwhelmed. Unmarried, FOB involved. Presenting for OB care as new patient, first antepartum visit.
HPI Believes LMP to be around: 1/24/2015 (“sometime between Valentine’s day and New Year’s Eve, probably the last week of January”). Unsure intercourse timing. Positive HPT: 3/17/2015 because she wanted to see if she “should have green beer or not”. Healthy, well-nourished female. C/o nausea, first thing in the morning for the last 2 weeks. Amenorrhea, increased frequency of urination, fatigue and breast tenderness began about 4 weeks ago. Denies dizziness, HA, visual disturbances, edema, or vomiting. Denies vaginal discharge, odor, bleeding and cramping. Eats fruits and hydrates appropriately. Counseled regarding nutrition: patient will attempt to include lean protein, dairy, and vegetables in her diet. Pt is not currently exercising, counseled regarding importance of exercise, and safe fitness level
OB/GYN History: G1P0. No hx of STI.
Yearly pap: Never had Pap, no Pap indicated at <21 yo per ACOG guidelines.
Past medical/surgical History:
- Allergies: NKDA
- No medical Hx
- Surgical Hx: wisdom teeth removed 2012
- Chewable PNV PO daily with 800 mcg Folic Acid
- Flu immunization October 2014, TDaP 2008
FH (Family History)
- Father died of colon cancer at age 54 (2009)
- Mother had cervical cancer (2010), is alive and stable
SH (Social/Personal History) Single, attending college PT for nursing, works FT as waitress, no drug use, 5-7 glasses of beer per week prior to pregnancy (1-2 at one time). Has not consumed alcohol since 3/1/2015. Never smoker. Christian, non-denominational No domestic violence. Does not have a cat, no litter box. Personal – Denies History of abuse, mental illness, depression, anxiety, or eating disorders.
GENERAL APPEARANCE: The patient is alert, oriented X 4, in no acute distress.
BP 118/68 P 68 Resp rate 18
Ht: 64” Wt: 115 lbs BMI: 19.7
HEENT: Head is normocephalic. The sinuses are nontender. Pupils are equal and reactive. The nares are patent. Oropharynx is clear without lesions.
NECK: Supple without lymphadenopathy. Thyroid normal size, without nodules.
HEART: Regular rate and rhythm.
LUNGS: CTA. No crackles or wheezes are heard.
ABDOMEN: Soft, nontender, nondistended with good bowel sounds heard. Inguinal area is normal.
EXTREMITIES: Without cyanosis, clubbing or edema. +2 DTR.
NEUROLOGICAL: Gross nonfocal. Denies HA, visual disturbances
Skin: Warm and dry without any rash. Neg CVA tenderness.
Fetus: Bimanual exam presents as approximately 9 wks gestation. FHTs 150s-160s. No fetal movement. US performed by MSV CNM- est gest age 9w2d. EDD 11/8/2015.
Urinalysis: neg protein, neg glucose
A: 30 yo G1P0 New OB, IUP 9w2d weeks by early U/S.
Mild Nausea of pregnancy.
- New OB Labs – T&S, CBC, G/C, RPR, Rubella, HBsAg, HIV, urine culture, HgbA1C
- Pap smear at age 21 yo per ACOG guidelines
- Fetal Genetic Screening – after counseling regarding options, pt has declined genetic screening (NT, 1st trimester screen, NIPT)
- Cystic Fibrosis Screen
- Daily PNV with folic acid
- Will be offered TDAP between 24-36 wks, offered flu vaccine when available 9/2015.
- Continue exercise as tolerated; walking, yoga, swimming, light weight bearing
- Adequate rest & hydration
-Nausea and vomiting: Small, frequent meals, crackers & ginger ale, ginger, Sea-bands (acupressure), Vit b6 & Unisom
-Exercise- continue usual activity. HR 150 bpm max.
-New exercise programs should be limited to walking, swimming, or other
-Wt gain: 25-35 lbs, varied, healthy diet with protein, fruit & veggies.
-TDAP & Flu vaccination recommendations
-Avoidance of Cat litter, gardening with gloves.
-Prenatal care schedule
-When to call office, emergency line number.
-Follow-up: RTO in 4 weeks &/or PRN
Example OB Labor Progress Note
S: Patient c/o cramping.
O: VSS, FHR baseline 135, + accelerations, intermittant late and variable decels, mod variability; Ctx: q1-4mins, MVUs 156-217 per IUPC; AROM for clear fluid with IUPC placement; vertex; SVE 4/60/-3
A/P: G1P0 IUP @ 38/3
IOL for Oligohydramnios- Expectant management
Category 2 tracing- Continuous electronic fetal monitoring, consider amnioinfusion if decelerations worsen
GBS Positive- PCN per protocol
Pain: Epidural PRN
Reassess in 2 hours- provide labor support and position changes; Clear liquid diet
Example OB Birth or Delivery Note
The patient was found to be completely dilated at 2119. After effectively pushing, the patient delivered a viable female infant over an in tact perineum at 2123. The cord was clamped x2 and cut after cessation of pulsation. Apgars 8,9. The placenta delivered, appearing to be in tact. Pitocin infusion began. The perineum was inspected and found to have a second degree laceration which was repaired with 3-0 vicryl in the usual fashion. EBL 250ml, fundus u/2. Mom and baby were left in stable condition, attempting to breastfeed.
OB Postpartum SOAP note
S: Denies complaints. Moderate mount of lochia, no clots, voiding well, ambulating PRN, + flatus, no BM, denies N/V, breastfeeding without difficulty
Vital signs T and Tmax, P RR, BP (include ranges)
ABD- Fundus firm, midline, u/2, nontender
laceration- clean, dry, minimal edema
Ext- +1 pitting edema, +2 DTRs, neg calf pain
24 year old now G2P2022, s/p NSVD doing well PPD#2
Prenatal labs: Rubella immune, Rh positive.
Pain well controlled
Routine postpartum care
Rx: Ibuprofen 600mg q 6 hours PRN pain; Colace daily
Micronor for contraception to start at 3 weeks
Lactation consult prior to Discharge
Vaginal rest, no heavy lifting
Follow up in 6 weeks at clinic with Dr. _____ or CNM ______
SOAP Notes in the Medical Field
The SOAP note is an important method of documentation in the medical field. It's imperative that every student learn the basics for writing a SOAP note in order to become a health care provider like a physician or an Advanced Practice Nurse.
These are just some examples of how to write a SOAP note with obstetric examples that one may encounter throughout your career. Do you have any different types of notes that you would like to see?