When documenting a patient history, what is the difference between subjective and objective data?

• A. Subjective data are observable; objective data are patient-reported
• B. Subjective data come from chart reviews; objective data come from patient statements
• C. Subjective data are signs; objective data are symptoms
• D. Subjective data are reported by the patient (symptoms); objective data are observable/measurable (signs).

Answer: (D)

In documenting a patient history, it’s important to separate what the patient tells you from what you can verify. Subjective data are the patient’s own reports of how they feel or what they’re experiencing—pain, dizziness, nausea, fatigue. These are symptoms because they come from the patient and can’t be measured directly by someone else. Objective data are what you can observe or measure—vital signs, physical exam findings, lab results, imaging, and other tests. These are signs because they can be seen, heard, felt, or quantified by anyone examining the patient.

So the distinction is: subjective data are reported by the patient (symptoms); objective data are observable/measurable (signs).