Patient data – the journey from patient to computer

The clinical data collection process starts when a patient starts telling a physician about his or her condition. This is known as the patient history, and since it is not observed directly by the physician, but instead recounted by the patient, the patient’s story is known as subjective information. In contrast, objective information comes from the physician and consists of the physician's own observations about the patient, from the physical examination, lab tests, and imaging studies, to other diagnostic procedures. Together, the subjective and objective information makes up the clinical note.

There are several types of clinical notes used in healthcare. The history and physical (H&P) is the most thorough and comprehensive clinical note. It is usually obtained when an outpatient physician sees a patient for the first time, or when a patient is first admitted to the hospital. Collecting all the data from the patient and typing up the...