Chart notes follow a standard structure, commonly the SOAP format capturing subjective complaints, objective findings, assessment, and plan. They document each encounter contemporaneously.
Electronic systems frequently generate notes partly from templates.
Alternative Names:
Clinical Note, Office Note
Why it Matters?
The subjective section records what the patient reported, which is where inconsistencies with litigation testimony surface, and the objective section records what the provider actually observed, which distinguishes reported symptoms from measured findings. Template-generated content is a growing complication, since copied-forward text can make a note appear to document an examination that was never performed.
Frequently Confused with
Related terms
Frequently asked questions
What does the SOAP format capture?
Why is templated content a problem?
