Subjective 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 Subjective Data

Obtaining subjective data requires good listening skills, as well as respect and empathy.  This data is often the assessment of what the patient, family, or care provider perceives to be the problem. Subjective data is collected through the process of interviewing the patient during the nursing history and during each patient encounter.  This information can only be described or verified by the patient.  Subjective data is also referred to as “symptoms”.  The best method to represent subjective data entries in a medical record is to use quotations.

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.

If you enter responses to subjective inquiry in an electronic medical record for the nursing admission data base, then; the answers in response to many of these questions are considered to be from the patient unless otherwise stated.  Quotations would not be necessary under this circumstance.  If the responses are obtained from a family member, it is necessary to record the historian to make the record clear where, or from whom the information was obtained.  Quotations are necessary when subjective entries are made that are not a part of the initial nursing data base questionnaire.  The following table demonstrates a comparison between subjective and objective entries.

Subjective Entries	Objective Entries
Patient is drinking well.	Drank 1,200 ml clear liquids between noon and 6 p.m.
Patient reported good relief from Demerol.	Pain in right hip decreased from 9/10 to 3/10.
Dorsalis pedis pulse present. Or Good pedal pulses.	Bilateral peripheral pulses in legs 2+/4+.
Voiding qs.	Voided 400 cc clear yellow urine in bedpan.
Patient is nervous.	Repeatedly asks about length of hospitalization, pain and discomfort, and time off from work.
Breath sounds normal.	Breath sounds clear to auscultation in all lobes, nail beds pink, equal chest expansion, no cough.
Bowel sounds normal.	Bowel sound present in all quadrants, abdomen flat, non-tender.  NPO since 11 a.m.