Can You Differentiate Between Subjective and
When writing reports, regardless of the
type of report (narrative vs. status report), it is important to differentiate between
subjective and objective findings. Reporting each type of finding has its purpose, but you
must understand the difference between the two.
First, subjective findings consist of the
symptoms that the patient reports and the ongoing changes during the course of treatment.
On an initial interview, the patient may complain of severe low back pain radiating into
the right leg and buttocks. Also, she experiences a secondary complaint of periodic
headaches. As her course of treatment progresses, she may report that the pain in her low
back has decreased and that the burning sensation in her leg is almost gone. Her
headaches, however, have remained the same. All of this information is classified as
subjective findings the patients report of his/her condition.
Subjective findings are important because
they constitute the patients reason for seeking treatment. Changes in subjective
findings justify the need for initial treatment and symptomatic changes justify the need
for ongoing care. On a status report, you might indicate "patient reports that low
back pain has lessened in intensity resulting in a decreased burning sensation in the
right leg." Keeping the insurance company apprised of the patients progress
lowers the risk that the insurance company may choose to stop reimbursement prematurely.
The other type of finding that a
chiropractic office should document on every patient is objective findings. Objective
findings consist of results of the x-rays and examination and any other procedure used to
establish diagnosis. Objective findings are used to formulate and substantiate the
patients diagnosis; they might indicate fixation or rotation of certain vertebrae.
They might also involve muscles, ligaments and tendons which move in conjunction with the
spinal column. Objective findings may include indications of pathology or biomechanical
dysfunction. They pinpoint the various areas of involvement and the severity of the
When reporting changes to an insurance
company in the form of a status report, it is important to identify symptomatic
(subjective) changes as well as objective changes which affect the diagnosis. As a result
of treatment, a severe sciatic condition may have been alleviated; the patient may still
have problems in the cervical region as the result of a whiplash syndrome. This problem
may be responding more slowly to treatment. Providing a status report and changing the
diagnosis to reflect progress/exacerbation/changes in condition is the type of
documentation needed by insurance companies. It avoids the problem of an insurance company
making an arbitrary determination that the patient has reached the maintenance phase of
As you type status reports, be sure to
differentiate in your mind (and in the report) between subjective and objective findings.
When you update an insurance company on the changes occurring with the patient, you are
justifying the need for ongoing care.
Contributed by: Marilyn Gard, President, Clinic Pro
Chiropractic Software, email@example.com
This information provided by Clinic Pro Chiropractic Software - your key to
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