29-year-old G2P1001 at 36 weeks 2 days by first-trimester ultrasound, consistent with LMP.
Concerns
Occasional painless tightening that is irregular and goes away with rest. Mild low back pain at the end of the day.
Pregnancy symptoms
No vaginal bleeding, no leakage of fluid, no regular painful contractions. Normal fetal movement.
Other symptoms
No headache, vision changes or right upper quadrant pain. Mild ankle swelling in the evenings that is gone by morning.
Medications
Prenatal vitamin daily.
OB / GYN history
G1: term spontaneous vaginal delivery at 39 weeks, 3,350 g, no complications. No abnormal Pap tests. This pregnancy: blood type O positive, rubella immune; HIV, hepatitis B and syphilis negative in the first trimester; normal 1-hour glucose challenge at 28 weeks; Tdap given at 28 weeks.
OObjective
Vital signs
BP 118/74, weight 162 lb (26 lb total gain). Urine dipstick: protein negative, glucose negative.
Fundal height
36 cm.
Fetal heart tones
140 bpm by Doppler.
Data
Leopold maneuvers: cephalic presentation, confirmed by bedside ultrasound. Trace bilateral ankle edema; calves soft and nontender.
AAssessment
Intrauterine pregnancy
At 36 weeks 2 days, uncomplicated. Fundal height matches gestational age. Normotensive without proteinuria or preeclampsia symptoms. Cephalic presentation. Irregular painless contractions consistent with Braxton Hicks; no signs of preterm labor.
Other problems
Dependent edema, physiologic. Low back pain, musculoskeletal, related to pregnancy.
PPlan
Tests due
Group B strep rectovaginal culture collected today (due 36 0/7 to 37 6/7 weeks); results will guide antibiotics in labor.
Education
Labor precautions: come to labor and delivery for regular painful contractions about every 5 minutes for an hour, leakage of fluid, vaginal bleeding, or decreased fetal movement. Preeclampsia warning signs: severe headache, vision changes, right upper quadrant pain, sudden swelling of the face or hands. Discussed pain relief options in labor, breastfeeding plans and postpartum contraception. Back pain: heat, stretching, supportive shoes.
Follow-up
Weekly prenatal visits until delivery; next visit at 37 weeks.
Fictional patient, written for learning. Follow your program's and facility's documentation standards.
Why this note works
The one-liner leads with G/P and gestational age, which frame everything else.
All four warning symptoms are documented: bleeding, fluid, contractions and fetal movement.
Fundal height, fetal heart tones and presentation are recorded and interpreted.
The plan names the test due at this gestational age (group B strep) and gives specific labor precautions.
What students often miss
Gestational age in the one-liner
Asking about all four warning symptoms
Labs and tests due at this gestational age
OB/GYN SOAP note template
Two patients at once: the pregnant patient and the pregnancy. Gestational age frames everything.
SSubjective
ID
Age, G_P____, gestational age by LMP or ultrasound.
Concerns
Pregnancy symptoms
Bleeding, leaking fluid, contractions, fetal movement (after ~20 weeks).
Other symptoms
Headache, vision changes, swelling.
Medications
Including prenatal vitamins.
OB / GYN history
OObjective
Vital signs
Especially blood pressure; weight.
Fundal height
Fetal heart tones
Data
Prenatal labs, ultrasound, urine results.
AAssessment
Intrauterine pregnancy
At __ weeks, uncomplicated or with complications listed.
Reading examples helps. Writing your own note and seeing exactly what you missed is what makes you better. SOAPy gives you a realistic case and checks your note section by section.