How should I document the subjective note for a 30‑year‑old male at a one‑week follow‑up after lumbar spine and left ankle radiographs, reporting improvement, no pain, swelling, warmth, and full painless range of motion?

Proper Documentation of Subjective Note for Follow-Up Visit

The subjective section should document the patient's self-reported symptoms, functional status, and concerns—not objective findings like inflammation or range of motion, which belong in the objective section. 1

Key Components of a Proper Subjective Note

Patient-Reported Symptoms

• Document the patient's description of pain status: Ask and record whether the patient reports improvement, worsening, or stability of lumbar and ankle pain compared to the previous visit 1
• Quantify symptom severity: Include patient-reported pain intensity (e.g., numeric rating scale 0-10) for both the lumbar spine and left ankle 1
• Characterize pain quality: Document whether the patient describes sharp, dull, aching, or radiating pain 1

Functional Impact

• Record activity limitations: Document what activities the patient can or cannot perform (e.g., walking distance, ability to work, sleep disturbance) 1
• Note changes in function: Ask whether the patient reports improvement in daily activities since the last visit 1

Patient Concerns and Goals

• Document the patient's perspective: Include what the patient is most concerned about and their treatment goals 1
• Record satisfaction with progress: Note whether the patient feels they are improving as expected 1

Corrected Example

Subjective: "30-year-old male returns for one-week follow-up after lumbar spine and left ankle radiographs. Patient reports his lower back pain has improved from 7/10 to 3/10 since last visit. Denies radiating leg pain. States left ankle pain has decreased from 6/10 to 2/10. Reports he can now walk without limping and has returned to work with minimal discomfort. No new symptoms. Satisfied with current progress."

Common Documentation Pitfalls to Avoid

• Do not include physical examination findings in the subjective section: Observations such as "no inflammation noted" and "normal ROM" are objective findings and belong in the objective section of the note 1
• Avoid vague statements: Replace "reports improvements" with specific details about what has improved and by how much 1
• Do not omit the patient's voice: The subjective section should reflect what the patient tells you, not what you observe 1