What distinguishes subjective data from objective data in documentation?

Subjective data is fundamentally distinguished by being derived from the personal experiences, perceptions, and feelings expressed by the patient. This type of data reflects how the patient interprets their symptoms, which can include descriptions of pain, feelings of anxiety, or other emotional responses. Since subjective data is based on what the patient verbally communicates about their condition, it plays a critical role in understanding the patient's perspective and informing clinical decisions.

Conversely, objective data is typically obtained through measurable, observable phenomena that can be assessed and verified by the healthcare provider. This includes vital signs, laboratory test results, and physical examination findings. The key difference lies in the source of the information; subjective data originates from the patient’s own narrative, while objective data stems from external assessments and measurable criteria. Understanding this distinction helps healthcare professionals accurately document and interpret patient information, leading to more effective care strategies.