Which type of documentation is based on opinions or perceptions and can be easily disputed?

• A. Subjective documentation
• B. Objective documentation
• C. Associated symptoms
• D. Pertinent negatives

Answer: (A)

Subjective documentation captures statements, perceptions, and opinions about the patient’s condition. Because it relies on what the patient says or how a clinician interprets those statements, it can be easily disputed since different people may describe the same experience differently or misremember details. In contrast, objective documentation records observable, measurable facts that others can verify, like vital signs or physical exam findings. For instance, noting the patient reports pain as “9 out of 10” is subjective, whereas recording a blood pressure of 132/84 or a heart rate of 78 is objective. Other data elements describe symptoms that accompany or follow a condition, or negatives that help rule things out, but the core idea here is the reliance on opinion or perception, which makes subjective documentation the best fit.