What is subjective documentation?

Subjective documentation refers specifically to the information that is reported by the patient or caregiver regarding the patient's condition, including symptoms, limitations, and their personal experience of the therapeutic process. This type of documentation captures the individual's perceptions and feelings, which are essential for understanding their unique situation and tailoring treatment accordingly.

By focusing on the patient's perspective, subjective documentation helps healthcare providers gauge the effectiveness of interventions and adjust treatment plans based on the reported experiences. This information is crucial for building a comprehensive picture of the patient's health status, as it provides insights that may not be captured through clinical measurements or objective findings alone.

In contrast, other aspects of documentation, such as clinical measurements or objective findings, concern observable and quantifiable data collected during examinations or treatments, which do not represent the patient's personal experiences.