Obstetrics & Gynecology (OB/GYN): Step-by-Step Guide on How to Write SOAP Notes

Written by SOAPNoteAI Editorial Team · Updated July 2026

Obstetrics and gynecology documentation spans two closely related but distinct domains within a single note style. Obstetric notes track a pregnancy across time using precise gestational dating, serial measurements, and trimester-specific screening, while gynecologic notes address menstrual and reproductive health, pelvic and breast examination, cancer screening, and contraception. A strong OB/GYN SOAP note must be numerically exact, longitudinally consistent, and clear about what was measured versus what was reported.

This guide provides comprehensive instructions for documenting both obstetric and gynecologic encounters, from the first prenatal visit through delivery and the postpartum period, and from the routine well-woman exam through problem-focused gynecologic visits. Whether you are recording gestational age by last menstrual period and ultrasound, a fundal height and fetal heart rate, a Pap and HPV co-test, or a contraceptive counseling discussion, mastering OB/GYN-specific documentation supports safe care, accurate coding, and medical-legal protection in one of the highest-stakes fields in medicine.

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What Makes OB/GYN Documentation Unique

Obstetrics and gynecology differs from other specialties in several fundamental documentation aspects:

1. Two Patients in Obstetric Care: Prenatal documentation must address both the pregnant patient and the fetus, with separate objective data (maternal vital signs versus fetal heart rate, growth, and movement).
2. Longitudinal, Date-Driven Structure: Obstetric care unfolds over roughly 40 weeks, and every entry is anchored to a gestational age that must remain internally consistent across the entire pregnancy.
3. Numeric Precision Is Non-Negotiable: Gestational age, estimated due date, fundal height, fetal heart rate, blood pressure, weight, and laboratory values directly drive clinical decisions and cannot be estimated or carried forward.
4. The Prenatal Flow Sheet Coexists With SOAP Notes: Routine antepartum data is often captured on a structured ACOG-style flow sheet, while narrative SOAP notes document problems, counseling, and clinical reasoning.
5. Intimate Examinations and Chaperone Documentation: Pelvic and breast examinations require documentation of consent, chaperone offer or presence, and sensitive findings.
6. Screening Guidelines Vary and Evolve: Cervical cancer screening, gestational diabetes screening, and group B streptococcus screening follow guidelines that differ by organization and update over time, so notes should state which guideline is being applied.

Subjective Section (S)

In an OB/GYN SOAP note, the Subjective section captures the reason for the visit, the relevant obstetric and gynecologic history, and the patient's reported symptoms. For prenatal visits this centers on interval pregnancy history; for gynecologic visits it centers on menstrual, sexual, and reproductive history.

Subjective Section (S) Components

1. Chief Complaint / Reason for Visit:

   • The primary reason for the encounter, whether a routine prenatal check, a well-woman exam, or a specific gynecologic concern
   • Example (OB): "Routine return prenatal visit at 28 weeks; patient reports good fetal movement and no concerns."
   • Example (GYN): "34-year-old presenting for annual well-woman exam and contraceptive counseling."

2. Obstetric History (Gravida/Para, GTPAL):

   • Total pregnancies and outcomes using GTPAL notation
   • Route, gestational age, and complications of prior deliveries
   • Example: "G3 P1011: one term vaginal delivery at 39 weeks (uncomplicated), one first-trimester spontaneous loss, one living child."

3. Current Pregnancy Dating (OB):

   • LMP and its certainty, EDD by LMP, EDD by ultrasound with dating basis, and the resulting confirmed gestational age
   • Example: "LMP certain; EDD by 8-week crown-rump length ultrasound consistent with LMP dating. Today's GA 28 weeks 3 days."

4. Interval Pregnancy History (OB return visits):

   • Fetal movement, uterine contractions, vaginal bleeding, leaking of fluid
   • Warning symptoms: severe or persistent headache, visual changes, right-upper-quadrant or epigastric pain, marked swelling, decreased fetal movement, dysuria
   • Example: "Reports active fetal movement, no contractions, no leaking fluid, no vaginal bleeding, and no headache, visual changes, or epigastric pain."

5. Menstrual History (GYN):

   • LMP, cycle length and regularity, flow (duration and heaviness), dysmenorrhea, intermenstrual or postcoital bleeding
   • Age at menarche, and menopausal status when relevant
   • Example: "Menses regular every 28 days, 5 days of moderate flow, mild dysmenorrhea, no intermenstrual bleeding."

6. Gynecologic and Sexual History:

   • Prior gynecologic diagnoses and surgeries, abnormal Pap history and any colposcopy or treatment
   • Sexual activity, number and gender of partners, dyspareunia, and STI history
   • Example: "Prior normal Pap tests; no history of abnormal cytology. Sexually active with one male partner; no dyspareunia."

7. Contraceptive and Reproductive Plans:

   • Current method and satisfaction, prior methods, and reproductive goals
   • Example: "Currently using combined oral contraceptives with good tolerance; interested in discussing a longer-acting option."

8. Relevant Personal and Family History:

   • Medical and surgical history affecting pregnancy or method eligibility (hypertension, diabetes, thromboembolism, migraine with aura)
   • Family history of breast, ovarian, uterine, or colon cancer and of hereditary conditions
   • Example: "History of migraine without aura. Mother with breast cancer at age 58."

9. Review of Systems (focused):

   • Genitourinary (dysuria, frequency, discharge), breast (masses, pain, discharge), and constitutional symptoms as relevant
   • Example: "Denies dysuria, abnormal vaginal discharge, breast masses, or nipple discharge."

10. Allergies and Current Medications:

    • Drug allergies with reactions, prenatal vitamins, and all current medications
    • Example: "No known drug allergies. Prenatal vitamin with iron and folic acid daily; no other medications."

Tips for OB/GYN Subjective Documentation:

• Always state how gestational age was established and keep it consistent with prior notes.
• For every return prenatal visit, explicitly document presence or absence of the classic warning symptoms.
• Record LMP for gynecologic visits and note whether the patient could be pregnant before any intervention.
• Distinguish confirmed history (records reviewed) from patient-reported history.

Example of a Subjective Section for a Return Prenatal Visit

Objective Section (O)

The Objective section in OB/GYN captures measured maternal and fetal data, physical examination findings, and any in-office or reviewed test results. Accuracy is paramount: every value must be measured at this visit or clearly attributed to a prior source.

Objective Section (O) Components

1. Maternal Vital Signs:

   • Blood pressure (critical for hypertensive disorders of pregnancy), heart rate, temperature, weight, and interval weight change
   • Example: "BP 118/72, HR 78, Temp 98.4F, weight 168 lb (up 2 lb from last visit)."

2. Urine Dipstick (prenatal):

   • Protein and glucose, and leukocytes/nitrites when indicated
   • Example: "Urine dipstick: protein negative, glucose negative."

3. Fundal Height (OB, second and third trimester):

   • Measured in centimeters; between roughly 20 and 36 weeks it correlates within about 2 cm of the gestational age in weeks
   • Example: "Fundal height 28 cm, appropriate for gestational age."

4. Fetal Heart Rate and Presentation (OB):

   • Fetal heart rate by Doppler (normal baseline 110 to 160 bpm), fetal movement, and presentation when assessable by Leopold maneuvers in later pregnancy
   • Example: "Fetal heart tones 148 bpm by Doppler, regular. Cephalic presentation by Leopold maneuvers."

5. Edema and Focused Maternal Exam:

   • Lower-extremity edema, deep tendon reflexes when preeclampsia is a concern, and any other focused findings
   • Example: "Trace bilateral ankle edema; no facial edema. Reflexes normal."

6. Breast Examination (GYN, when performed):

   • Inspection (symmetry, skin changes, nipple discharge) and palpation of all quadrants and axillae, with any mass described by clock position, distance from nipple, size, consistency, mobility, and tenderness
   • Example: "Breasts symmetric, no skin changes, no nipple discharge; no dominant masses; no axillary lymphadenopathy."

7. Pelvic Examination (GYN, when performed):

   • External genitalia, speculum findings (vaginal walls, discharge, cervix appearance and any lesions or friability), and bimanual findings (cervical motion tenderness, uterine size/position/mobility, adnexal masses or tenderness)
   • Note specimens collected and that a chaperone was offered or present
   • Example: "External genitalia normal. Speculum: normal vaginal mucosa, physiologic discharge, cervix without lesions. Bimanual: no cervical motion tenderness, uterus normal size and mobile, no adnexal masses or tenderness. Chaperone present."

8. In-Office and Point-of-Care Tests:

   • Wet mount, pH, whiff test, urine pregnancy test, or point-of-care glucose, only when actually performed
   • Example: "Urine pregnancy test negative in office."

9. Laboratory and Imaging Results Reviewed:

   • Results transcribed from the source report, with the date and reference context; do not record pending results as if resolved
   • Example: "One-hour 50-gram glucose challenge result reviewed today (value on report); interpreted below."

10. Cervical Examination (labor or specific indications):

    • Dilation in centimeters, effacement percentage, and station; Bishop score components when assessing readiness for induction
    • Document only when a cervical exam was actually performed
    • Example: "Cervical exam deferred; not indicated at this visit."

OB/GYN Objective Documentation Framework Template

Example of an Objective Section for a Return Prenatal Visit

Assessment Section (A)

The Assessment section synthesizes the subjective and objective data into a clinical impression. In obstetrics it establishes where the pregnancy stands and flags any complications; in gynecology it states the diagnosis or the screening status and any problems identified.

Assessment Section (A) Components

1. Pregnancy Status and Gestational Age (OB):

   • A concise problem statement anchoring the pregnancy, GTPAL, gestational age, and overall status
   • Example: "Intrauterine pregnancy at 28 weeks 3 days, G3 P1011, progressing normally."

2. Obstetric Problems and Risk Factors:

   • Any complications (gestational diabetes, hypertensive disorders, growth concerns, isoimmunization, preterm labor risk) and pertinent risk factors
   • Example: "Screening for gestational diabetes in progress; awaiting confirmatory testing based on today's result."

3. Gynecologic Diagnosis / Screening Status (GYN):

   • The working gynecologic diagnosis or the well-woman screening status
   • Example: "Well woman, due for cervical cancer screening; abnormal uterine bleeding, likely anovulatory."

4. Differential Diagnosis (when relevant):

   • Alternative explanations for a gynecologic problem, ranked by likelihood
   • Example: "Abnormal uterine bleeding: differential includes anovulation, structural causes (polyp, fibroid), and, less likely, endometrial pathology given age and risk factors."

5. Fetal Assessment (OB):

   • Growth adequacy by fundal height, reassuring or non-reassuring status, and presentation trend
   • Example: "Fundal height appropriate; fetal heart rate reassuring; movement reported normal."

6. Risk Stratification and Care Level:

   • Low-risk versus high-risk pregnancy designation and any indications for additional surveillance or referral
   • Example: "Currently low-risk pregnancy pending glucose testing results."

OB/GYN Diagnostic Approach

For systematic assessment, consider:

For Prenatal Care:

• Gestational age accuracy and internal consistency
• Trimester-appropriate screening completed versus outstanding
• Maternal complications (blood pressure, glucose, anemia, infection)
• Fetal status (growth, heart rate, movement, presentation)

For Gynecologic Problem Visits:

• Pregnancy excluded when relevant
• Structural versus functional causes
• Malignancy risk factors and screening indications
• Infection and STI considerations

For Well-Woman Care:

• Age-appropriate cancer screening due dates
• Contraceptive needs and eligibility
• Preventive counseling and immunizations

Example of an Assessment Section for a Return Prenatal Visit

Plan Section (P)

The Plan section documents the diagnostic and treatment steps, screening ordered, counseling provided, and follow-up. In obstetrics the plan is strongly tied to gestational age milestones; in gynecology it addresses the specific problem, screening, and contraception.

Plan Section (P) Components

1. Trimester-Appropriate Prenatal Screening and Labs (OB):

   • Screening ordered or scheduled per gestational age (aneuploidy screening, anatomy ultrasound, gestational diabetes screening, Rh antibody testing and anti-D immune globulin at 28 weeks for Rh-negative patients, group B streptococcus culture at 36 to 37 weeks)
   • Example: "Anti-D immune globulin not required (Rh positive). Group B streptococcus culture to be obtained at 36 to 37 weeks."

2. Diagnostic Workup (GYN):

   • Laboratory studies, imaging (pelvic or transvaginal ultrasound), or procedures (endometrial biopsy, colposcopy) as indicated
   • Example: "Order pelvic ultrasound to evaluate for structural cause of abnormal uterine bleeding."

3. Medications and Treatments:

   • Specific drug, dose, route, and frequency; verify safety in pregnancy and lactation when applicable
   • Example: "Continue prenatal vitamin; iron supplementation deferred pending CBC."

4. Contraceptive Plan and Procedures (GYN):

   • Method chosen, counseling on effectiveness and side effects, and procedure documentation for insertions
   • Example: "Levonorgestrel intrauterine device selected after counseling; insertion scheduled; pregnancy reasonably excluded today."

5. Cervical Cancer Screening (GYN):

   • Collection method, result-handling plan, and next-due interval per the adopted guideline
   • Example: "Co-testing (cytology and high-risk HPV) collected today; results to be communicated and next screening interval determined by result."

6. Patient Education and Counseling:

   • Warning signs to report, nutrition, activity, immunizations (influenza, Tdap in pregnancy, others as indicated), and preventive counseling
   • Example: "Reviewed preterm labor and preeclampsia warning signs; Tdap planned at 27 to 36 weeks."

7. Referrals:

   • Maternal-fetal medicine, oncology, surgery, genetics, lactation, or behavioral health as indicated
   • Example: "Refer to nutrition and, if confirmatory testing is positive, to the diabetes-in-pregnancy program."

8. Follow-Up and Documentation:

   • Interval to next visit (which shortens as pregnancy advances), monitoring plan, and coding to be completed by the clinician
   • Example: "Return in 2 weeks; visits will increase to weekly at 36 weeks. Billing codes to be confirmed and completed by the documenting clinician."

Prenatal Visit Cadence and Milestone Reference

Typical low-risk prenatal visit intervals and gestational-age milestones (adjust to the individual patient and current guidelines):

• First visit / first trimester: Confirm pregnancy and dating; initial prenatal labs (CBC, blood type and Rh, antibody screen, rubella immunity, hepatitis B surface antigen, HIV, syphilis, urine culture, and cervical cancer screening if due); prenatal vitamins
• 11 to 14 weeks: First-trimester aneuploidy screening (nuchal translucency and/or cell-free DNA)
• 15 to 22 weeks: Second-trimester serum screening if elected
• 18 to 22 weeks: Fetal anatomy ultrasound
• 24 to 28 weeks: Gestational diabetes screening (one-hour 50-gram glucose challenge, followed by a three-hour 100-gram test if abnormal in the common two-step approach)
• 28 weeks: Repeat antibody screen and anti-D immune globulin for Rh-negative, unsensitized patients
• 36 0/7 to 37 6/7 weeks: Group B streptococcus rectovaginal culture
• Visit cadence: Roughly every 4 weeks until 28 weeks, every 2 weeks from 28 to 36 weeks, then weekly until delivery

Example of a Plan Section for a Return Prenatal Visit

Gynecologic Well-Woman and Problem Visit Documentation

Gynecologic visits use the same SOAP structure but emphasize menstrual and reproductive history, the pelvic and breast examination, cancer screening, and contraception. Two common scenarios are the preventive well-woman visit and the problem-focused visit (for example, abnormal uterine bleeding or a suspected infection).

Key Gynecologic Documentation Elements

1. Menstrual and Bleeding History:

   • LMP, cycle regularity, flow, dysmenorrhea, intermenstrual, postcoital, or postmenopausal bleeding
   • For abnormal uterine bleeding, characterize frequency, duration, and volume, and screen for anemia symptoms

2. Cervical Cancer Screening Status:

   • Method, date, result, and next-due interval per the adopted guideline. Screening organizations differ, so state which guideline is being followed
   • ACOG and the USPSTF describe starting at age 21 (cytology every 3 years for ages 21 to 29; for ages 30 to 65, cytology every 3 years, primary high-risk HPV every 5 years, or co-testing every 5 years). The American Cancer Society's 2020 guidance suggests starting at age 25 with primary HPV testing preferred

3. Breast Health:

   • Breast exam findings, breast cancer risk factors, and mammography status per age and risk

4. Sexual and STI History:

   • Sexual activity, partners, symptoms, and risk-based STI screening

5. Contraception:

   • Current method, satisfaction, reproductive goals, eligibility considerations (CDC US Medical Eligibility Criteria), and shared decision-making

Example of a Gynecologic Well-Woman Visit Note

Prenatal Flow Sheet vs Narrative SOAP Note

A defining feature of obstetric documentation is that routine antepartum data is often recorded on a structured prenatal flow sheet (such as the ACOG Antepartum Record), while narrative SOAP notes document problems, counseling, and clinical reasoning. Understanding when to use each is central to efficient, defensible OB documentation.

The ACOG-Style Prenatal Flow Sheet

The flow sheet is a longitudinal grid that captures, at every visit, the date, gestational age, weight, blood pressure, urine dipstick (protein and glucose), fundal height, fetal heart rate, presentation, fetal movement, and edema, alongside a running record of laboratory results, ultrasounds, immunizations, and problem lists. Its strengths are:

• Trend visibility: Serial blood pressures, weights, and fundal heights are visible at a glance, which is how patterns (such as a plateauing fundal height or a rising blood pressure) are detected
• Completeness: The grid prompts the clinician to record every routine parameter at every visit
• Efficiency: Routine data entry is fast and standardized

When a Narrative SOAP Note Is Needed

A narrative SOAP note complements the flow sheet whenever the visit involves more than routine data:

• A new symptom or complication (bleeding, decreased fetal movement, elevated blood pressure, suspected labor)
• Counseling that requires documentation (genetic screening decisions, birth planning, results disclosure)
• Clinical reasoning and a differential (evaluating a size-dates discrepancy or an abnormal screening result)
• Procedures or referrals

Documentation Best Practice

In practice, most obstetric visits generate both: the flow sheet captures the numeric trend, and a brief SOAP note captures the interval history, any problems, counseling, and the plan. When using an AI scribe, the narrative SOAP note is what is generated from the conversation; the numeric flow-sheet values (fundal height, fetal heart rate, blood pressure, weight, and dipstick results) should be confirmed against what was actually measured and entered on the flow sheet. The AI should never populate a flow-sheet number that was not measured and stated.

Postpartum Visit Documentation

The postpartum visit assesses maternal physical recovery, emotional health, infant feeding, contraception, and the transition of any pregnancy-related conditions to ongoing care. ACOG frames postpartum care as an ongoing process rather than a single visit, ideally beginning within the first weeks after birth.

Key Postpartum Documentation Elements

• Delivery summary: Route, gestational age at delivery, complications, estimated blood loss, and infant status
• Physical recovery: Fundal involution, lochia (amount and character), perineal or cesarean incision healing, and breast and lactation status
• Bladder and bowel function: Continence, retention, constipation, and hemorrhoids
• Mood screening: A validated tool such as the Edinburgh Postnatal Depression Scale, with the score documented and a safety assessment when indicated
• Contraception and interpregnancy planning: Method selection appropriate to lactation and time since delivery
• Chronic-condition transition: Postpartum glucose tolerance testing after gestational diabetes, blood pressure follow-up after a hypertensive disorder of pregnancy, and thyroid or mental-health follow-up as indicated

AI-Assisted Documentation for OB/GYN

AI-powered documentation tools can meaningfully reduce the documentation burden of obstetric and gynecologic encounters, which are frequent, history-rich, and counseling-heavy. At the same time, obstetrics is one of the least forgiving specialties for numeric error, so the division of labor between AI capture and human verification matters more here than almost anywhere else.

How AI Can Help with OB/GYN Documentation

• Interval prenatal history: AI captures the spoken review of fetal movement, symptoms, and warning-sign screening efficiently
• Menstrual and gynecologic history: AI structures menstrual, sexual, contraceptive, and family-history narratives
• Counseling documentation: AI records contraceptive counseling, screening discussions, and anticipatory guidance
• Efficiency: Less time charting means more time with patients across a high-volume clinic schedule

What AI Captures Well in OB/GYN

• Reason for visit and interval history
• Menstrual, obstetric, sexual, and contraceptive history narratives
• Warning-symptom review of systems
• Counseling, education, and follow-up plans
• Postpartum recovery and mood-screening discussion

What Requires Careful Review

• Gestational age and estimated due date (must be internally consistent and dating-method attributed)
• GTPAL and prior delivery details (confirm the digits)
• Fundal height, fetal heart rate, fetal presentation, and estimated fetal weight (measured values only)
• Blood pressure, weight, and urine dipstick (flow-sheet numbers)
• Cervical exam findings (dilation, effacement, station) when performed
• All laboratory and ultrasound values (transcribe from the report; never record pending results as resolved)
• Medication names and doses and allergies (including Rh immune globulin, magnesium sulfate, and oxytocin)

Tips for Using AI with OB/GYN Documentation

1. State gestational age and its basis explicitly: "Twenty-eight weeks and three days, dating confirmed by first-trimester ultrasound" rather than "about seven months"
2. Verbalize measured numbers clearly: "Fundal height twenty-eight centimeters, fetal heart rate one hundred forty-eight" rather than "measuring on track"
3. Distinguish measured from reported: "Fetal heart rate one hundred forty-eight by Doppler today; anatomy ultrasound normal per outside report"
4. Flag pending results: "Glucose challenge result reviewed" only if it has actually returned; otherwise "glucose challenge pending"
5. Confirm exact medications and doses, and never let the tool infer a value that was not stated
6. Review every number in the generated note against the flow sheet, monitor, or lab report before signing

For more details, see our complete AI-Assisted Documentation Guide.

Free OB/GYN SOAP Note Template

Speed up your documentation with our comprehensive OB/GYN SOAP note template. This template includes essential elements for both obstetric and gynecologic encounters, from prenatal visits through the well-woman exam.

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