Medical records
SOAP note
A SOAP note is the standard format for clinical documentation — Subjective, Objective, Assessment, Plan — and the structure behind most of the progress notes in a medical record.
The four sections, in the order they appear:
- Subjective — what the patient reports: symptoms, history, complaints, in their words. “Patient states low back pain is 8/10, worse since the accident.”
- Objective — what the clinician observes and measures: exam findings, vitals, test results. “Straight-leg raise positive on the right; strength 4/5.”
- Assessment — the clinician’s diagnostic conclusion, often a numbered problem list.
- Plan — what happens next: medications, referrals, imaging, follow-up interval.
Why it matters for legal readers
The S/O boundary is the most important line in the chart. The Subjective section is the patient’s account passed through the clinician’s pen — which makes it both a record of complaints and, for the defense, a catalog of admissions (“denies prior back pain”) that will be read against every earlier chart. The Objective section is the clinician’s own findings, and carries different evidentiary weight for exactly that reason.
For case work, the gaps talk too: a Plan that orders an MRI with no later imaging report in the file means a record is missing; an Assessment that never changes across months of visits speaks to plateau; a Subjective complaint that appears for the first time months post-incident is a causation problem in the making.
In the fact record
FactMarshal reads notes section-aware — a reported symptom, an exam finding, and a diagnosis enter the chronology as different kinds of facts, each cited to its page, so “the patient said” and “the doctor found” never blur.