How to Interpret Medical Records Like a Doctor (When You’re a Lawyer)

4-20-2025

By Dr. Howard Friedman, MD | Veteran | U.S. Army Medical Corps | Internal Medicine | HHOM LLC

Understanding the weight of medical evidence is key to building a strong case. At HHOM LLC, we break down complex records with clinical precision—so you don’t have to guess what matters.

Behind each chart, a story hides—

In ink and codes, the truth resides.

But not all eyes can trace the thread,

Where symptoms speak and plans are read.

Let skill decode what forms conceal—

To turn the record into something real.

---Dr. Howard Friedman MD

Reading medical records isn’t easy—especially when you’re trained in the law, not medicine. But if you’re representing a client whose case hinges on a diagnosis, injury, or disability, you need to be able to extract meaning from clinical notes, progress summaries, and specialist reports. You don’t need to be a physician—but you do need to think like one.

The best place to start is understanding the structure. Most clinical notes follow a format called SOAP, which stands for Subjective, Objective, Assessment, and Plan. Whether it's an initial evaluation, an ER admission, or a daily progress note, SOAP is the scaffolding.

The Subjective section begins with the patient's story. This includes the complaints the patient is reporting—what hurts, what’s not working, what brought them in. A good note also includes “negatives”—things the patient denies. These are just as important as the symptoms themselves. This section may also include information from prior medical records, family history, and personal habits like smoking or alcohol use. It’s the narrative. Read it like the opening chapter of a novel—it sets the scene.

Then comes the Objective. This includes the physical exam and vital signs—temperature, blood pressure, pulse, respiratory rate. The exam is usually head-to-toe. Is the story from the history lining up with what the doctor found on physical examination? That’s your job as the reader: compare and contrast.

Also part of the Objective section are test results—bloodwork, imaging, pathology, and more. These are the cold, hard data points. Again, look for alignment: do the labs and scans support the patient’s complaints?

Next is the Assessment—where the doctor gives their interpretation. Based on the story and the evidence, what’s the diagnosis (or list of possible diagnoses)? This is the heart of the note: the physician’s professional opinion. Be alert to inconsistencies or contradictions. Does the assessment match the data? Does it reflect the patient’s symptoms? Is something missing?

Finally, there’s the Plan. What is the doctor going to do next? More tests? Medications? Surgery? Observation? Follow-up? The Plan gives you insight into what the provider thinks is most important at that moment.

Progress notes follow the same format but are typically shorter. These daily notes may not repeat the entire history, but they’ll show how the patient is responding to treatment. Watch for patterns over time. Is the condition improving? Worsening? Changing? A trend will often emerge—and it’s your job to trace that arc.

Medical records can be dense and filled with jargon, but don’t be intimidated. Free and trustworthy resources are available. The National Institutes of Health (NIH) offers accessible explanations. Platforms like Osmosis, and even educational YouTube channels, can walk you through complex terminology or conditions.

Ultimately, remember this: every record is written by a provider who is interpreting the case from their perspective. Sometimes they’re right. Sometimes they miss something. Either way, the record leaves clues. Learn to follow them.

And if you ever get stuck—if the language is unclear, the diagnosis doesn’t make sense, or the logic doesn’t hold up—you’re not alone. You can always Ask Dr. Howard. I’m here to help you untangle the clinical knots and bring clarity to the case..

—Dr. Howard Friedman, MD

Board-Certified | Internal Medicine | Veteran | U.S. Army Medical Corps

Founder of Howard’s House of Medicine (HHOM LLC)

https://www.hhomllc.com

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Frequently Asked Questions:

Question: What is the SOAP format in medical records?

Answer: SOAP stands for Subjective, Objective, Assessment, and Plan. It’s a standard framework for clinical notes: starting with the patient’s symptoms, moving through exam findings and test results, leading to the physician’s diagnosis and treatment plan.

Question: Why is the Assessment section of a medical note so important?

Answer: The Assessment is the physician’s interpretation of all the collected information. It’s where the diagnosis—or differential diagnosis—is made. This section carries weight in both legal and medical decision-making, making it vital for attorneys to review closely.

Question: How can attorneys get help interpreting complex medical records?

Answers: Attorneys don’t have to do it alone. HHOM LLC offers expert analysis and support from Dr. Howard Friedman—an internal medicine physician and veteran with over 30 years of experience. His insights help clarify confusing records and strengthen disability claims.