The key distinction
Shadow Health subjective data is the history and experience reported by the patient. Record the meaning, relevant context and source; keep an unanswered question separate from a documented denial.
On this page
What counts as Shadow Health subjective data?
Subjective data is the account you obtain from the patient: symptoms, concerns, experiences and relevant history. Keep the source identifiable when information comes from a family member or another person. OpenStax explains the distinction between reported information and observable or measurable findings.
The deciding question is how the information was obtained. A pain rating remains the patient’s report even when it uses a number. A temperature the patient remembers taking at home is a history statement; a temperature measured during the current encounter has a different source and time.
Collect both the concern and the details needed to understand it. “Feels tired” and “reports feeling tired every afternoon for the past week” carry different information. Use the more detailed wording only when those details were actually established.
Organize the history around the assigned encounter
Read the activity title and course requirements before building an interview outline. A focused encounter and a broader health history may require different coverage. Use the available categories as prompts for assessment, then follow the patient’s responses.
- Current concern: why the patient is seeking care and how the concern is described.
- Symptom context: relevant onset, timing, frequency, changes, associated concerns and effects on daily activities.
- Relevant history: information about prior conditions, medications and allergies, with the source clearly identified.
- Patient context: routines, support, concerns and other history required for the assigned activity.
This is an organizing framework, not a universal scored-item list. Your course instructions determine the scope. Avoid importing an entire history from another visit because the patient name is familiar.
Use follow-up questions to clarify the patient’s meaning
The following are invented teaching examples. They demonstrate interview structure and are not verified Tina Jones responses or a scoring script.
| Patient statement | What remains unclear | Example follow-up |
|---|---|---|
| “My hands feel stiff.” | When it happens and how long it lasts. | “When do you notice the stiffness?” |
| “It makes work difficult.” | Which activities are affected. | “What task is harder to do?” |
| “I take it sometimes.” | How the patient describes actual use. | “When did you last take it?” |
Ask one clear question, read the answer and decide whether more clarification is needed. A question appearing in the transcript does not prove that the patient supplied the information you were seeking.
Separate reported, denied and unestablished information
These three states deserve different treatment in your working notes. Reported means the patient supplied the information. Denied means the patient was asked and reported that the concern was absent. Unestablished means the detail remains unclear or was not obtained.
Do not convert a missing response into “denies.” If the conversation does not establish a time frame, frequency or other required detail, mark the gap for review and follow the activity’s documentation requirements.
Use quotation marks for exact words. Otherwise, paraphrase faithfully and identify the source with wording such as “the patient reports.” Keep interpretation separate from the history that supports it. The objective data guide explains how to handle examination findings alongside that account.
Apply the approach to your Tina Jones activity
Before reviewing a Tina Jones example, match the activity and visit context to your assignment. Use your actual encounter as the source of findings. A study document can help you examine coverage and organization, but it cannot establish what happened in your own interview.
For interview review, start with the listed contents and preview of the Tina Jones Health History resource. If you are studying a respiratory encounter, inspect the Respiratory resource for the relevant history material. Choose according to the assigned activity and available document contents.
Once your account is accurate, use the Shadow Health documentation guide to organize it into the required note format.
Review your subjective data before writing the note
Use this checklist while reviewing a practice encounter. Your selections are not submitted.
Common questions
Is a pain rating subjective or objective?
A rating reported by the patient is subjective, even when expressed as a number. Record it as the patient’s account; keep observed behavior or current measurements separately identifiable.
Does a question in the transcript mean the information was collected?
Check the actual answer. A question alone does not establish the requested detail, and an unclear response may require follow-up.
Are these Tina Jones answers?
The examples teach classification and question structure. They are not verified case responses. Use the findings from your assigned encounter and follow your course requirements.
Sources and context
Source pages checked October 23, 2026. This independent study guide follows the listed sources; your assigned activity and instructor requirements determine the required assessment and documentation.
Find the matching study resource
Check the available interview and history materials for the activity you are studying.
Preview Health History resources →Use examples to study the assessment process and complete graded work independently under your course’s rules.