Past medical history - subjective or objective??

[RNFinally12]

I feel so stupid, but I get caught up with small things. Is a past medical history subjective or objective? I was thinking subjective because it is what the client tells you. It's been a while since I have done this..

Thank you.

[PiedPiperRN]

You crack me up, since I know why you are asking this question... :)

I have been told it is sujective, unless it is charted.

[RNFinally12]

I actually found an admission form for a hospital that shows that it is subjective. Can you tell I over analyze. I am a wreck when it comes to anything with nursing school.

Thank you.

[Flame_07]

I think subjective also, because only the patient can verify the information.

[Baloney Amputation, BSN, LPN, RN]

I'm an acute care medical transcriptionist. In listening to H&Ps and other notes containing a past medical history section, the past medical history is often subjective, but it occasionally contains objective information that backs up (or enhances or clarifies) the subjective information, particularly if the admitting doctor is familiar with the patient and/or can access hospital and clinic records. Sometimes the admitting physican can only assume the past medical history by a medication list, because the patient can't provide a history.

The current diagnoses from lab tests and imaging are included in the assessment section and not in the past medical history, unless there is something like a CT scan showing old strokes.

[llg, PhD, RN]

I was taught it could be either, depending on the specifics. For example, if the patient says he lost his leg in a car accident in 1988, you could consider that objective information. It is verifiable, even though we have nothing but his report (and the absence of his leg) to see at that moment.

[willstocka]

Depending on the book... its either. And this question drove me crazy in school as well. NCLEX and Evolve/Elsevier consider it to be SUBJECTIVE (2016)