The Art of the Subjective
The Subjective section is where you tell the patient's story. It's more than just recording symptoms ā it's capturing the context, impact, and nuance of their experience. A well-written Subjective helps any reader understand why the patient sought care and what they're going through.
OLDCARTS Framework
OLDCARTS is a systematic approach to gathering and documenting the History of Present Illness (HPI). Each letter represents a key aspect of the symptom:
ā¢ **O ā Onset**: When did it start? Sudden or gradual?
ā¢ **L ā Location**: Where is it? Does it radiate?
ā¢ **D ā Duration**: How long does it last? Constant or intermittent?
ā¢ **C ā Character**: What does it feel like? Sharp, dull, burning, pressure?
ā¢ **A ā Aggravating Factors**: What makes it worse?
ā¢ **R ā Relieving Factors**: What makes it better?
ā¢ **T ā Timing**: When does it occur? Pattern?
ā¢ **S ā Severity**: How bad is it? (0-10 scale)
š OLDCARTS Example: Chest Pain
**CC**: "My chest hurts" **HPI using OLDCARTS**: ā¢ **Onset**: Started 2 hours ago while climbing stairs ā¢ **Location**: Substernal, radiates to left arm and jaw ā¢ **Duration**: Constant since onset ā¢ **Character**: Pressure, "like an elephant sitting on my chest" ā¢ **Aggravating**: Exertion, deep breathing ā¢ **Relieving**: Rest provides mild relief, nitro not tried ā¢ **Timing**: First episode of this severity ā¢ **Severity**: 8/10 **Associated symptoms**: Diaphoresis, shortness of breath, nausea **Pertinent negatives**: No recent trauma, no fever, no cough
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Chief Complaint Best Practices
Document the chief complaint in the patient's exact words using quotation marks. This preserves important context and can reveal the patient's understanding of their condition. ā CC: "I feel like my heart is racing and I can't catch my breath" ā CC: Palpitations and dyspnea
What to Include in Subjective
A complete Subjective section includes:
- ā¢Chief complaint in patient's words
- ā¢Complete HPI using OLDCARTS or similar framework
- ā¢Relevant past medical history
- ā¢Current medications and allergies
- ā¢Relevant social history (smoking, alcohol, drugs, occupation)
- ā¢Relevant family history
- ā¢Review of systems (pertinent positives and negatives)
- ā¢What the patient has already tried for relief
Pertinent Negatives
Pertinent negatives are symptoms the patient denies that are relevant to the differential diagnosis. They demonstrate your clinical reasoning and help rule out serious conditions.
**Example for chest pain:**
"Patient denies fever, cough, leg swelling, recent immobility, or history of blood clots."
This documents that you considered pulmonary embolism and gathered information to help rule it out.
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Common Subjective Mistakes
Avoid these errors: ā¢ Including objective data (vital signs, exam findings) in the Subjective ā¢ Paraphrasing the chief complaint instead of using patient's words ā¢ Omitting pertinent negatives ā¢ Failing to document medication compliance ā¢ Not asking about prior episodes or treatments ā¢ Missing red flag symptoms in the review of systems