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Before becoming a psychiatrist, before being an allergy/immunologist, I performed a six-month rotation during my internship as a physician in the emergency room of a major medical center. In plain language, I was an ER doctor. 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. ”She looked back down at her Dad. “I’ve been a bit naughty Daddy, and I loved it.” Giggle. Tom just snored.“I should get ready for school now I don’t want to miss the buss.” We disengaged and she went to her room to dress. I followed and enjoyed watching her pick out a pair of panties and a top and skirt. She put her hair into a pony with a pink bow then she slipped into some short white socks and a pair of saddle back shoes. She looked adorable.“I’ll see you this afternoon then” I said.“OK by.”I watched her walk to the end of the drive and the bus stop for her. I left a note for Tom to ring if he needed me and left.Each morning Fern would come over and we would have our naked breakfast with lots of kisses and cuddles and cums. I had a busy few days that I needed to go away for and when I returned Tom asked if I could drop him at the hospital as they wanted to change his plaster for a walking style boot with a rubber foot. We got back just as Fern came home from school. Tom asked if I.
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