In documentation, what does Subjective data capture?

In documentation, what does Subjective data capture?

• A. Patient's symptoms and feelings
• B. Clinician's observations
• C. Laboratory results
• D. Imaging studies

Answer: (A)

Subjective data captures the patient's own report of symptoms and feelings. It includes what the patient describes about their experience—pain quality and intensity, location, timing, duration, and how these symptoms affect daily life, as well as mood, fatigue, or other personal perceptions. This information comes from the patient’s perspective and isn’t measured or observed directly by the clinician. In contrast, objective data are the clinician’s observations or test results, such as vital signs, physical exam findings, laboratory values, and imaging. For example, a patient saying, “I have sharp chest pain for two hours” is subjective, while a measured heart rate or an ECG result is objective.

Subjective data captures the patient's own report of symptoms and feelings. It includes what the patient describes about their experience—pain quality and intensity, location, timing, duration, and how these symptoms affect daily life, as well as mood, fatigue, or other personal perceptions. This information comes from the patient’s perspective and isn’t measured or observed directly by the clinician. In contrast, objective data are the clinician’s observations or test results, such as vital signs, physical exam findings, laboratory values, and imaging. For example, a patient saying, “I have sharp chest pain for two hours” is subjective, while a measured heart rate or an ECG result is objective.