Which components of the medical chart are considered subjective?

The components of a medical chart considered subjective are primarily the History of Present Illness (HPI) and the Review of Systems (ROS). Subjective data is information that comes directly from the patient, capturing their personal experiences, feelings, and symptoms.

HPI involves detailed information that the patient provides regarding their current illness, including the nature, duration, and context of their symptoms. This is inherently subjective, as it reflects the patient's perception and description of their condition.

Similarly, ROS covers a broad range of symptoms across various body systems that the patient may or may not have experienced. It relies on the patient’s account of their symptoms, making it subjective as it is based on their self-reporting rather than objective findings.

In contrast, other components like the Physical Exam and Medical Decision Making (MDM) typically involve the clinician’s observations and evaluations, which are based on measurable findings and not on the patient's self-reported experiences. The ED course and Triage reflect the clinical processes and decisions made by healthcare providers, while Orders and results consist of objective data that are documented based on tests and interventions performed.