Whether you are working with a lawyer or are trying to get Social Security disability / Supplemental Security Income (SSI) benefits on your own, you will probably be reading medical records at some point.
Here is a quick primer on how a large portion of medical records are set-up:
Most of the medical records I see from doctors in Colorado, whether from primary care providers, specialists, or other doctors use the SOAP notes system. That is, the notes are divided into Subjective, Objective, Assessment, Plan (or Prognosis): S. O. A. P.
- Subjective – this is where the doctor notes what you told him/her. What brings you in today? How do you feel? What are your symptoms? How are you reacting to treatment/medications?
- Objective – this is the signs and findings the doctor can objectively measure. This includes things like x-ray or lab findings, range of motion, or other results or observations.
- Assessment – this is typically the summary of your diagnosis.
- Plan – this is the course of treatment the doctor recommends or any changes to your current treatment or medications.
Not all doctors use the SOAP notes system. Hospitals, eye doctors and other medical providers may use other systems, but by being able to recognize the SOAP notes system, you will have a leg up on understanding what your doctor’s records are saying.