Subjective and Objective Documentation in Behavioural Health
Proper documentation is an important element of behavioral health. It can act to promote patient safety, improve the quality of patient care, minimize errors, and ensure legal and regulatory compliance (Wertheimer, 2019). The two forms of documentation in behavioral health are subjective and objective documentation. Subjective information is based on personal opinions, points of view, and judgment, whereas objective information is observable, measurable, and fact-based. For instance, subjective documentation may include gathering information about what the clients share about their symptoms and what they perceive as their goals and needs for treatment. Objective documentation includes observable, measurable, and reproducible findings from physical examination and laboratory or diagnostic tests. Examples of objective documentation include x-ray reports, lab test results, and blood pressure readings. Including subjective and objective information during documentation in behavioral health is important.
Subjective information gives important clues about the patient’s functioning and health needs. It may include the patient’s feelings, perceptions, or concerns. Subjective information helps get a picture of what the patient is experiencing, thus positively impacting the care plan development. Subjective information helps identify problematic issues for patients as well as individual strengths that can be useful in delivering the desired health outcomes (Podder et al., 2021). Objective information involves the healthcare provider’s engagement of different senses, such as sight, hearing, touch, and smell. Examples of objective data include laboratory results, physical examination findings, and vital signs (Podder et al., 2021). Objective information offers an evidence-based understanding of patients’ health conditions. It also influences the care plan and treatment options that can help improve the health outcomes for patients. The inclusion of both objective and subjective information can thus help achieve better health outcomes for patients.
References
Podder, V., Lew, V., & Ghassemzadeh, S. (2021). SOAP notes. In StatPearls [Internet]. StatPearls Publishing.
Wertheimer, M. (2019). Documentation in Behavioural Health. American Professional Agency. https://www.apa.org/members/your-membership/benefits/insurance-documentation.pdf
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Subjective and Objective Documentation in Behavioural Health
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