In family practice, precise and thorough documentation of a Gyne/PAP visit is essential. The SOAP (Subjective, Objective, Assessment, Plan) template is a standard format that ensures all necessary information is captured efficiently. Here's how to structure and format your clinical notes correctly, using a detailed example.

Subjective (S)

The subjective section captures patient-reported information. For a Gyne/PAP visit, include:

Menstrual Status: Document if the patient is pre-menopausal, menopausal, or post-menopausal. For instance, "Menopausal."

Periods: Note the regularity, e.g., "Regular."

Cycle Length: Specify the length of the menstrual cycle, such as "28 days."

Contraception: Record any use of contraception, e.g., "None."

STI Concerns: Mention if there are any concerns, e.g., "No."

Hormone Replacement Therapy: Indicate if the patient is on hormone therapy, e.g., "Yes."

Additional details like the date of the last PAP test and history of abnormal results are crucial. For example: "Last PAP: 2022-05-15. No history of abnormal PAP results."

Objective (O)

This section includes findings from the physical examination:

General Appearance: "Well-nourished, alert, and oriented."

Gynecological Exam: Describe the tools and observations, such as "Medium speculum used to visualize cervix."

• Vulva: "Normal appearance."

• External Genitalia: "No lesions or abnormalities noted."

• Vagina: "Pink, no signs of estrogen depletion."

• Cervix: "Normal, no lesions or discharge."

Document any tests performed, such as "PAP test performed without complications."

Assessment/Plan (A/P)

The assessment and plan provide diagnosis and next steps:

Diagnosis: "Routine gynecological exam, no abnormalities detected."

PAP Test Status: "Pending results."

Follow-up Plan: "Schedule follow-up in 6 months for repeat PAP."

Patient Notification Plan: "Patient will be notified via phone or portal of test results."

Automating Documentation with Notis AI Medical Scribe

Documenting patient interactions can be time-consuming, but AI medical scribes like Notis AI Medical Scribe offer a transformative solution for family practice. Notis streamlines the creation of clinical notes, allowing practitioners to focus more on patient care.

Key Benefits of Notis AI Medical Scribe

Time Efficiency: Notis significantly reduces documentation time by leveraging voice-to-text technology, saving healthcare providers up to 2 hours a day.

Ease of Use: Integrated with WhatsApp, Notis provides a familiar platform, eliminating the need for additional software.

High Accuracy: With an accuracy rate of 99%, Notis ensures reliable transcription of medical notes, supporting 56 languages to cater to diverse patient populations.

Comprehensive Documentation: Notis converts consultations into structured SOAP notes instantly, enhancing documentation quality and consistency.

By incorporating Notis into family practice, healthcare professionals can enhance their efficiency, reduce burnout, and improve patient care through precise and automated documentation processes. Notis serves as a valuable tool for any family practice looking to optimize their patient documentation workflow.