Gynecological SOAP Note Template S: CC: Use pt’s words in quotation marks
HPI: Include onset, duration, progression, timing, amount, aggravating factors, alleviating factors, treatments already tried, previous h/o similar sx? &c. Include pertinent negatives. History of contraceptive use.
OB/Gyn History: Include anything pertinent to the CC or that would affect tx plan.
Menstrual history:LMP!, age at menarche, length of cycle, average number of days of menses, characteristics of flow, regularity of cycles, descriptions of any irregularities and/or accompanying symptoms. (Normal cycle: 21 – 35 days, menses last 4 – 7 days)
Pregnancy history: GTPAL. Chronological order: year, duration, type of birth, sex, baby’s weight, complications, is the child alive and well? TABs, SABs, ectopics, molar pregnancies.
History of STIs: what type of infections, what tx, how frequently, complications? & screen for HIV risk. Number of current sexual partners and during lifetime. condom use?
Does she douche?
Urologic health: occurrence and frequency of bladder & UTI & kidney infections, incontinence
Previous Paps? Date of last Pap, results. Ever had an abnormal Pap? What follow up occurred and have subsequent screenings been normal?
Sexual history: Is she sexually active and if so with men, women, or both? Is she satisfied with her current sexual function? Does she or her partner have any concerns or problems? History of sexual assault?
Contraceptive use: is she currently using a method? Is she satisfied with it or does she desire a change? Discuss her past methods if relevant for the visit.
Abnormal symptoms: fully describe, e.g. pelvic pain, noting relationship in time with menstrual cycle, association with sex, tampon use, or other factors. Describe any vaginal bleeding not associated with menses.
General Medical History: Include any pertaining to the CC or that would affect tx plan (Ex: noncontributory or negative).
Need for any well-woman recommendations:mamo, colpo, glucose, lipid panel, TSH, vaccines? Etc
Medications: OTC, rx, herbal, &c
Allergies: meds, environmental, latex, shellfish, iodine
FMH: Include any pertinent to the CC or that would affect tx plan (alcoholism, cancer, endocrine, genetic/chromosomal, hematological, mental retardation, CVD, congenital anomalies, GI, lung, neuro, renal, psychiatric, multiple gestation, DV. (Ex: noncontributory)
Psychosocial/Social History/Habits: Include use of tobacco, drugs, ETOH. Current living situation. Occupational, exposure to hazards. Relationships, recent sexual history/partners, monogamous?
Safety: Use of seat belts, helmets, firearms in household; DV/IPV
Chart Review: Relevant information from chart, place either in S or O
General: Observation of pt – is she anxious, nervous, in pain? If so, identify the behaviors she demonstrates. Does she look older than stated age? State of health (ex: malnourished, well-nourished, obese)? Can use NAD
PE: Include only systems r/to CC. Organize by systems and list in head to toe order. Sometimes no exam is necessary, and this should be noted (e.g., “deferred, not examined”)
HEENT: Normocephalic. EOMI. PERRLA. TMs pearly gray bilaterally. No nasal drainage or lesions. Mouth and throat without lesions or exudates, teeth in good repair, gums pink.
Neck: No lymphadenopathy or thyromegaly. (Ex: euthyroid)
Chest: CTA throughout.
Heart: RRR, no m/g/r
Breast exam: Size (if remarkable, e.g. small, large, pendulous), nipples, symmetry. Skin changes (rashes, lesions, dimpling, retraction). Note masses, lumps, or tenderness. Description of a mass: Location (can draw picture or describe location as on a clock face), size, shape, consistency, mobility distinctness, nipple, skin over lump, tenderness, lymphadenopathy. (Ex: No masses, lumps, or tenderness, symmetrical without discharge. Axilla WNL)
Abdomen: Non-tender, no hepatosplenomegaly
Extremities: FROM ? no varicosities
External Genitalia: Mons including hair distribution (triangle escutcheon, no lesions), labia majora and minora, clitoris, Bartholin’s and Skene’s glands (often grouped with urethra as BUS), hymen, introitus, perineum. Piercings?
Vagina: Color, rugation, odor, tone. (Cystocele, rectocele, discharge, inflammation, lesions, masses) (Ex: rugated, pink, no lesions or discharge, good tone)