OB/GYN

OB/GYN documentation across the reproductive lifespan

Prenatal, well-woman, contraception, menopause — ScribeMDPro drafts appropriate notes for each phase of care.

OB/GYN spans a wider range of encounter types than almost any other specialty — a single day may include an initial prenatal visit, a routine well-woman exam, a contraception counselling appointment, a menopause management visit, and a same-day procedure. Each requires different documentation structure and vocabulary. ScribeMDPro was configured with distinct templates for prenatal, gynecologic, contraceptive counselling and menopause visits, and the underlying language model was tuned on OB/GYN transcripts to handle terminology (G/P notation, LMP, cervical exam findings, HRT regimens) accurately. Contraception counselling and shared decision-making are captured in a structure that supports both continuity and billing.

Documentation challenges we solve

  • The same clinician may see prenatal, well-woman, contraception and menopause patients in a single session
  • G/P notation and menstrual history require specific formatting
  • Contraception counselling must document options discussed, patient priorities and shared decision-making
  • Prenatal visits accumulate longitudinal data (weight, BP, fundal height, FHR) that should carry forward

What clinicians gain

  • Distinct templates per visit type auto-selected based on chief complaint
  • Standardized G/P and LMP formatting
  • Contraception counselling captured with options, priorities and decision
  • Longitudinal prenatal data structured for easy trend review

How it works

  1. Step 1
    Start ambient capture

    Open ScribeMDPro before the OB/GYN encounter and start recording — the patient never has to talk to a device.

  2. Step 2
    Focus on the patient

    Conduct your normal history and exam. Take history as usual — the AI selects the appropriate template (prenatal, well-woman, contraception, menopause) automatically.

  3. Step 3
    Auto-drafted note

    A structured SOAP note appears seconds after the visit ends, formatted for your specialty.

  4. Step 4
    Review, sign, export

    Edit inline, copy to your EMR, download as PDF, or push through supported integrations.

Example SOAP output

S: 32yo G2P1 at 28 weeks by LMP, confirmed by first-trimester US. Normal fetal movement, no contractions, no bleeding or fluid leak. No headaches or visual changes.
O: BP 118/72, wt +18lb since booking. Fundal height 28cm, FHR 148, cephalic presentation.
A: 28-week uncomplicated singleton pregnancy.
P: 1h GTT today. Tdap administered. RTC 4 weeks. Fetal kick counts reviewed.

Illustrative only. Clinicians retain final responsibility for the record.

Frequently asked questions

Does it distinguish prenatal from gynecologic visits?

Yes. Template selection is automatic based on chief complaint and confirmed to the clinician.

Can it document contraception counselling?

Contraception counselling has a dedicated template that captures options, priorities, and the shared decision.

How does it handle procedural notes (IUD, endometrial biopsy)?

Procedure notes are generated alongside the visit note with site, technique, and disposition.

Does it support menopause management?

Menopause visits are supported natively, including HRT regimen documentation and shared decision-making.

Related pages

Try ScribeMDPro on your next visit

Start free — no credit card, no install. Sign up in under a minute and record your first ambient SOAP note today.