Which term describes the current visit's symptoms and patient-reported history?

• A. Subjective Information
• B. Objective Information
• C. Plan
• D. Chief Complaint

Answer: (A)

Subjective information covers what the patient reports about their symptoms and history, since these details come from the patient’s experience and cannot be verified by someone else through measurement. When a patient describes pain, onset, quality, timing, and related symptoms, that falls under subjective data. In a typical medical note, the subjective section includes the chief complaint and the history of present illness, as well as other patient-reported history like past medical, family, or social history.

Objective information, by contrast, consists of what the clinician observes or measures directly—physical exam findings, vital signs, and results from tests or labs. The plan outlines the proposed treatment and next steps, not the patient’s reported symptoms. The chief complaint is the patient’s stated reason for the visit, but it is a specific element within the subjective data rather than the overall category describing all patient-reported symptoms and history.

So, describing the current visit’s symptoms and patient-reported history as subjective information is the best fit because it highlights that this data originates from the patient’s own report.