GENERAL SURVEY

Patient data is considered either subjective or objective, and it can be collected from multiple sources.

Subjective data is information obtained from the patient and/or family members and offers important cues from their perspectives. When documenting subjective data, it should be in quotation marks and start with verbiage such as, “The patient reports…” or “The patient’s wife states…”  It is vital for the medical assistant to establish rapport with a patient to obtain accurate data for why the patient is being seen.

Example. An example of documented subjective data obtained from a patient assessment is, “The patient reports pain severity of 2 on a 0-10 scale.” 

There are two types of subjective information, primary and secondary. Primary data is information provided directly by the patient. Patients are the best source of information about their bodies and feelings, and the medical assistant who actively listens to a patient will often learn valuable information while also promoting a sense of well-being. Information collected from a family member, chart, or other sources is known as secondary data. Family members can provide important information, especially for infants and children or when the patient is unable to speak for themselves.

Objective data is anything that you can observe through your senses of hearing, sight, smell, and touch while assessing the patient. Objective data is reproducible, meaning another person can easily obtain the same data. Examples of objective data are vital signs, physical examination findings, and laboratory results.

Example. An example of documented objective data is, “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”

Assessment data is collected in three ways: during a focused interview, during physical examination, or while reviewing laboratory and diagnostic test results.

Interviewing includes asking the patient questions, listening, and observing verbal and nonverbal communication. Reviewing the chart prior to interviewing the patient eliminates redundancy in the interview process and allows the medical assistant to hone in on the most significant areas of concern or need for clarification. However, if information in the chart does not make sense or is incomplete, the medical assistant should use the interview process to verify data with the patient.

When beginning an interview, ask the patient what they are being seen for.  Listen carefully and ask for clarification when something isn’t clear to you. Patients may not volunteer important information because they don’t realize it is important for their care. By using critical thinking and active listening, you may discover valuable cues that are important. Sometimes medical assistant students can feel uncomfortable with asking personal questions because of generational or other differences. Don’t shy away from asking questions that are important to know.  

Be alert and attentive to how the patient answers questions, as well as when they do not answer a question. Nonverbal communication and body language can be cues to important information that requires further investigation. A keen sense of observation is important, and any concerns should be reported to the provider.