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Dosage Calcs

Objective vs Subjective Data in Nursing

Keeping reported information separate from observations is one of the most important documentation skills.

Educational use & privacy

Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.

Nursing Notes Privacy & Safety

Subjective

Information reported by the patient/client or another source, such as a family member. Only the person experiencing it can confirm it. Quote or attribute it.

  • Patient states "my chest feels tight."
  • Patient rates pain 4/10.
  • Spouse reports the patient fell at home last week.
  • Patient says she feels dizzy when standing.
  • Patient reports nausea since breakfast.

Objective

Observable or measurable information: what you see, hear, feel, smell or measure.

  • Heart rate 96, regular.
  • Skin pale, cool and moist.
  • Walked 20 feet with walker.
  • Urine output 400 mL over 8 hours.
  • Grimacing and holding abdomen when turning.

Tricky cases

  • Numbers are not always objective. A pain rating of 6/10 is a number, but the patient reports it, so it is subjective.
  • Reports from others are subjective. "Daughter states…" is subjective; record the source.
  • Describe behavior, not emotions. "Crying, holding tissues" is objective. "Sad" is an interpretation unless the patient says it ("Patient states 'I feel sad'" is subjective).
  • Interpretations are neither. "Appears comfortable" is an inference. Record what you observed instead.

Classify these fictional statements

1. Patient states "I feel short of breath."

2. SpO2 92% on room air.

3. Patient rates anxiety 7/10.

4. Left calf 2 cm larger than right.

5. Son says his father hasn't eaten in two days.

6. Patient rubbing left shoulder and wincing.

7. Patient reports ringing in both ears.

8. Temperature 38.2 °C oral.

0 of 0 answered correctly. Nothing is saved.

Where this shows up

Sources