SUBJECTIVE VS OBJECTIVE DATA
SUBJECTIVE VS OBJECTIVE DATA
Subjective Data
What the patients TELLS you
“I feel nauseous every time I eat” OR Pt. reports nausea when eating
“My throat hurts when I swallow” OR Pt. reports his throat hurts when he swallows
Subjective data is documented in the CC, HPI, Allergies, Medication, PMH, SH, FMH, Health Maintenance, and Review of Systems sections.
*If you need to ask the pt a question to get and answer it’s SUBJECTIVE DATA
PRESENTATION TITLE
2
Objective DATA
What YOU observe
Pupils are PERRLA
Pt is AAO x3
Lungs are clear
Objective Data is what you would document in the Physical Exam section of the SOAP note.
*If it’s something YOU see, hear, or touch (examine) then it’s OBJECTIVE DATA.
PRESENTATION TITLE
3
CASE STUDY
A 65-year-old female comes to your office for a routine physical examination. She is a new patient to your practice. Does not appear in acute distress, responses are appropriate and appears reliable source. Alert, oriented to person, place, time and situation. Well-nourished, skin warm, dry and intact. States she feels a lump in her rt breast which has been present for 1 week. States lump isn’t painful but is worried because her mom died at age 72 from breast cancer. She states her father died at the age of 83 of a stroke. She has hypertension and takes Lisinopril 20 mg PO daily. She also take Lipitor 10 mg daily for HLD and Multivitamins OTC. She states she is allergic to PCN and gets a rash. She has a 61 yo sister with diabetes and a 60 yo brother with HTN. Her last mammogram was last year and was normal, pap test was 3 years ago, and she is UTD on her colonoscopy. Last tetanus was 5 yrs ago. Denies ever having a dexascan. She is married in a monogamous relationship with her husband. They have 2 children. Her son is 32 without medical problems and her daughter is 28 and has anxiety. She has a master’s degree in software engineering and worked full-time for Microsoft until last month when she retired. She denies any financial stressors. Goes to church every Sunday. She does not smoke, drink alcohol, use any recreational drugs. She walks 3 miles 4 days a week and follows a vegan diet. She denies fever, chills, weight loss or weight gain. On examination her blood pressure is 120/88, pulse is 70 beats/min, respiratory rate is 18. Height is 64 inches and weight is 125lbs. Normocephalic. Pupils size 3 mm, equal and reactive to light. Extraocular eye movements intact to six directions. She denies hearing changes and dizziness. States she used to have migraines which were triggered by stress but hasn’t had any since she retired. Tympanic membranes gray with adequate cone of light bilaterally. Mucous membranes pink and moist. No palpable masses, thyromegaly, lymphadenopathy or JVD. No bruits auscultated. She denies shortness of breath, dyspnea on exertion, swelling or chest pain. She denies abdominal pain, nausea, vomiting or changes in appetite. Denies rashes or bug bites. She does use seatbelts. Denies anxiety or depression. Regular heart rate and rhythm, S1 and S2. Breath sounds clear bilaterally to auscultation. Her abdomen is soft, non-tender, non-distended, normoactive bowel sound. No organomegaly or guarding. Denies numbness or tingling. She reports she has pain and stiffness in her knees in the mornings from her arthritis. Takes Tylenol with some relief.
Everything in red is subjective data
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