In a patient's progress notes, which entry would be considered a subjective observation?

In a patient's progress notes, which entry would be considered a subjective observation?

• A. Blood pressure is 120/80
• B. Patient complains of feeling dizzy
• C. WBC count is elevated
• D. X-ray shows pneumonia

Answer: (B)

The main concept is telling apart subjective versus objective information in progress notes. Subjective observations are what the patient reports about their symptoms or feelings—things only the patient can describe. “Patient complains of feeling dizzy” fits this, because dizziness is an experience reported by the patient and not directly measured by the clinician. The other entries are objective data: blood pressure is a measured vital sign, WBC count is a lab value, and an X-ray finding is an imaging result. These are observable or quantifiable facts obtained without relying on the patient’s description. Documenting both types of data is important for a complete clinical picture and guides assessment and plan.

The main concept is telling apart subjective versus objective information in progress notes. Subjective observations are what the patient reports about their symptoms or feelings—things only the patient can describe. “Patient complains of feeling dizzy” fits this, because dizziness is an experience reported by the patient and not directly measured by the clinician.

The other entries are objective data: blood pressure is a measured vital sign, WBC count is a lab value, and an X-ray finding is an imaging result. These are observable or quantifiable facts obtained without relying on the patient’s description. Documenting both types of data is important for a complete clinical picture and guides assessment and plan.