What key information should be included in the Subjective assessment?

The subjective assessment is a critical component of patient evaluation that focuses on the patient's personal account of their condition. It is essential to gather information that provides insight into the patient's experience and perspective, primarily through their chief complaint and the history of the present illness.

The chief complaint is the primary reason the patient is seeking medical attention, capturing their most pressing concern or the symptom that brought them in. The history of present illness offers a detailed narrative that elaborates on the chief complaint, including the onset, duration, severity, context, and associated symptoms. This information is vital for understanding the patient's condition from their viewpoint, informing further examination and treatment.

In contrast, while current medications and vital signs, physical examination results, and demographics or insurance information are important in the overall assessment and management of the patient, they do not form part of the subjective data. Instead, these elements typically belong to the objective assessment or administrative paperwork, operating on a different level of clinical information that does not directly reflect the patient's subjective experience.