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Duke UniversityNURSING 442Initial+OB+SOAP+Note+Sample

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Initial OB SOAP note date ID info: 21 year old WF CC: OB physical Allergies: Iodine, shellfish Subjective: HPI: Unplanned pregnancy for this G1 P0000 at 9 5/7 wks by LMP, confirmed by transvagi ... nal ultrasound. No complaints, except feels slightly tired. No nausea/vomiting. No vaginal spotting/bleeding, abdominal pain or cramping. Was ambivalent about pregnancy at first, “I’m okay with it now”. FOB is supportive, as is her mother and sister. Menstrual: LMP 12/25/2005, regular timing. Menarche: 12 yo, reg. menses q 26-28 days x 4-5days, mild dysmenorhea. Sexual hx: Monogamous with steady boyfriend of 2 years, 4 lifetime partners, all male. h/o Chlamydia 2 yrs ago, rx;d. This boyfriend without known STIs, never tested. Describes sexual activity as ‘good’, though last month she has been too tired for it. Was using condoms until about 6 months ago, when switched to calendar method [Show More]

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