Objective Data and Patient Assessment

Objective data includes measurable and observable criteria that are specific to a clinical problem.  Objective indicators are factual that can be observed.  These types of data are obtained through the assessment process using the techniques inspection, palpation, percussion, and auscultation when examining the patient.  Objective data is also referred to as “signs”. In medicine a symptom is generally subjective while a sign is objective.  

Subjective data is information provided by the patient or significant knowledgeable other.  Objective data is information a healthcare provider obtains directly through observation or measurement, from patient records, or from diagnostic studies.

I will address What are Symptoms? What are Signs? is subsequent posts.  Stay tuned.

Examples of Objective Data

Height, weight

General appearance: Well-nourished, well-hydrated, well-developed white woman or man in no acute distress.  Appears stated age, looks pleasant, smiles readily, speech clear and evenly paced; alert and oriented x 4; calm and cooperative.

Caloric intake

Vital signs: Blood pressure, respiration, temperature, heart rate, hemodynamic measures

Level of consciousness

Tears, crying

IV solution, rate infusing, site description

Lab values (hemoglobin, hematocrit)

Presence of indwelling catheter

Functional mobility

Diaphoresis

Dyspnea

History of illness (include dates)

Lung sounds

Sputum production, frequency, amount, character

Oxygen use

Bed position (e.g., low position, semi-Fowler’s)

Restlessness

Visitors present (be as specific as possible)

Skin integrity: color, lesions, scars, bruises, edema, moisture, texture, temperature, turgor, vascularity

Loose or liquid stools 

Does your electronic medical record have a place where you can enter the "details" of your objective data? Or is it in general terms like, within normal limits, within expected range?  The extent of your vulnerability may come down to the "details".  Take time to record completely your patient care.