Comprehensive SOAP Note: Abnormal Uterine Bleeding
Eight to ten pages, and the assignment lists the elements it wants. Using a recognised classification for the differentials is what turns a long note into a good one.
Editorial process
Last reviewed · August 16, 2026
A SOAP note is a structure, and AUB has its own framework
The assignment lists its required elements, so the first job is mechanical: age, race and ethnicity, partner status, current health status and chief complaint, contraception method, and a history in four parts — medical, family medical, gynaecologic and obstetric — plus personal and social history as relevant. Each of those is a checkable line and leaving one out costs marks for no intellectual reason. Contraception and partner status are easy to overlook and directly relevant here, since hormonal contraception is both a cause of irregular bleeding and a treatment for it. Then hold the SOAP discipline through a long document: subjective is what the patient reports, objective is what you found and measured, and a physical finding that drifts into the subjective section is the most common structural error in a note this length. Read the required list twice and tick each element off as you draft.
The differential is where a strong note separates itself, and the way to do that is to work from a classification rather than a list. The PALM-COEIN system splits causes into structural — polyp, adenomyosis, leiomyoma, malignancy and hyperplasia — and non-structural — coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not yet classified. Using it does three things at once: it shows a system rather than recall, it makes your diagnostics follow logically, since structural causes point to imaging and non-structural ones to laboratory work, and it makes malignancy impossible to omit, which matters because endometrial cancer is the diagnosis you cannot afford to miss. Order your differentials by probability with the most likely first, justify each from your own findings, and let the management plan follow the diagnosis you actually reached rather than covering every possibility. State the follow-up interval and the red flags that would bring her back sooner.
Likely learning objectives
Inferred from the brief — check these against your own rubric.
- 01Complete every required element of a comprehensive gynaecologic history.
- 02Maintain SOAP structure across a long document.
- 03Generate differentials from a recognised classification system.
- 04Align diagnostics and management with the reasoning that produced them.
Read the full question
Review every instruction before using the planning guidance that follows.
Turn the brief into deliverables
- 01All listed demographic and history elements.
- 02A review of systems and a documented physical exam.
- 03Labs, tests and other diagnostics with rationale.
- 04Differential diagnoses ordered by probability.
- 05A management plan with treatment, education and follow-up.
- 06Eight to ten pages in APA format.
History through management, in SOAP order
Subjective: demographics and chief complaint
Record the required demographic elements and the presenting problem.
Subjective: the four histories
Document medical, family, gynaecologic and obstetric history.
Objective: examination and review of systems
Record findings, including pertinent negatives.
Diagnostics
Order tests and justify each from the differential.
Assessment: differentials by classification
Work through structural and non-structural causes and rank them.
Plan: treatment, education and follow-up
Set out management, patient education and review intervals.
Classification systems and current guidance for AUB
Recommended databases
- NCBI Bookshelf
- ACOG practice bulletins
- PubMed Central
- The assigned Schuiling and Likis chapters
Search sequence
- 1.Take the classification system from a current reference and use its terms exactly.
- 2.Check the current guidance on when endometrial sampling is indicated by age and risk.
- 3.Look up contraceptive causes of irregular bleeding so the history connects to the differential.
- 4.Verify laboratory thresholds rather than approximating them.
Reference shortlist
These are authoritative starting points, not a ready-made bibliography. A qualified reviewer must confirm that each source fits the assignment and supports the claim beside which it is cited.
Nothing here is cleared for citation until you have read it.
- 01
Abnormal Uterine Bleeding
StatPearls, NCBI Bookshelf · 2024
Abnormal uterine bleeding with the classification system, evaluation and management pathway.
- 02
SOAP Notes
StatPearls, NCBI Bookshelf · 2023
SOAP note structure, for keeping a long document disciplined.
- 03
Exploratory Data Analysis: Frequencies, Descriptive Statistics, Histograms, and Boxplots
StatPearls, NCBI Bookshelf · 2023
Interpreting the laboratory values your diagnostics will return.
- 04
Health Literacy
MedlinePlus, National Library of Medicine · 2025
Pitching the patient education section at a level the patient can use.
Review before submission
Common mistakes
- Omitting contraception method or partner status, both explicitly required.
- Mixing objective findings into the subjective section.
- Listing differentials with no classification or ordering.
- Failing to address malignancy in a patient whose age warrants it.
Submission checklist
- Is every listed element present?
- Are subjective and objective sections cleanly separated?
- Do the differentials come from a recognised framework?
- Does the plan follow from the primary diagnosis rather than from all of them?
Use this guide to plan and review your own work. Follow your institution's rules and read our academic-integrity policy.
Written by
Aaron Bishop
MA, Education
assignment interpretation and research-methods coaching across disciplines
Aaron leads the EssayCrackers editorial desk. He works on how assignment briefs are read — what a rubric is actually asking for, and where students most often answer a different question than the one set.
Reviewed by
Dr. Nathan Cole
PhD, Rhetoric & Composition
Argumentation and thesis development
Nathan teaches first-year composition and directs a university writing center. He reviews EssayCrackers guides for argumentative soundness and citation accuracy.