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SOAP stands for Subjective, Objective, Assessment, and Plan. The following is an actual medical transcript that I dictated and was typed by a medical transcriptionist back in the mid-'70s:S: 14 y/o WF presented to the ER with C.C. of vaginal bleeding x 36h. Pt. states that she had sexual intercourse for the first time and was worried because the bleeding has not lessened and is ongoing.O: HEENT WNL, chest clear to auscultation, heart RRR, Abd S NT ND. Ext. genitilia slightly inflamed. Pelvic exam shows 2cm superficial laceration running laterally parallel to the vaginal canal. Significant trauma to hymenal folds shows recent tearing, probably secondary to sexual penetration. The hymen appears lacerated at the 10, 3, 5, and 7 o'clock positions. The tear at the 10 o'clock position extends into the vaginal wall past the mucosa and appears to be the primary contributor for bleeding. Some signs of early granulation present, bleeding appears to be moderate oozing without any arterial or. I was so shocked I didn't even close my eyes. I just hung there, staring at his closed eyes in front of mine. Then I felt his tongue glide past my lips and into my mouth. He began massaging the inside of my lips with his tongue. He placed his hand on the side of my neck, his thumb in front of my ear.My eyes closed then, let me tell you. I felt a rush of pins and needles all over my body. A dull excitement that consumed me. I thought I was going to faint. The excitement of kissing someone for the first time. It possessed me.I sucked his tongue further into my mouth and began circling my own tongue around it. Our mouths became aggressive. Areas of desperate longing. It felt so good.He withdrew his tongue from my mouth and pulled his face away from mine. I opened my eyes to find his staring back at me. Then he looked down.I felt something on my waist. His hand. He was pulling down my panties. I quickly reached down and grabbed his hands to stop him. He looked back up at me. He didn't.
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