In medical documentation, which statement best describes objective information?
Choose an answer, then check it.
Medical Office Assistant · Administrative Procedures and Office Management
Documentation Standards: Objective vs Subjective
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5 questions here, of 85 in this lesson’s practice set. Answers stay hidden until you check.
Which statement best describes subjective information in a patient's health record?
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A patient says, 'My stomach has been hurting for two days.' How should this statement be classified in the record?
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The assistant records a temperature of 101.2 degrees F. This is an example of which type of information?
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A blood pressure reading of 118/76 mmHg recorded in the chart is best classified as:
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Study tools & related lessonsYou’ll learn to · Related
You’ll learn to
- Distinguish objective information from subjective information in patient documentation.
- Document observable facts rather than personal interpretations or opinions.
- Apply documentation standards for accuracy, timeliness, and completeness.
- Quote patients accurately and record subjective data in the patient's own words.
- Use neutral, person-centered language that is free of judgment and stigma.
Sources & references
- U.S. Department of Health and Human Services — Health Information Privacy (HIPAA)
- U.S. Department of Health and Human Services — Summary of the HIPAA Privacy Rule
- Office of the National Coordinator for Health IT — Privacy, Security, and HIPAA
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