DISTINGUISHING BETWEEN SUBJECTIVE AND OBJECTIVE CHARTING

DISTINGUISHING BETWEEN SUBJECTIVE AND OBJECTIVE CHARTING

The most common error most nurses make when they chart is writing value judgments and opinions –
subjective information – rather than factual or objective information. Subjective information reflects
how the nurse feels about the patient’s condition, not the patient’s condition itself. Here are some
subjective entries, with their objective alternatives.

SUBJECTIVE CHARTING OBJECTIVE CHARTING

She’s drinking well. Drank 1,500 ml liquids between 7 a.m. and noon.

She reported good relief from Demerol. Pain in right hip decreasing, patient described as
“like a dull toothache.”

Dorsalis pedis pulse present. Good pedal pulses. Peripheral pulses in legs 2+/4+ bilaterally.

Moves legs and feet well. Leg strength 5+/5+ bilaterally all major muscle
groups. Sensation intact to light touch, pin; denies
numbness or tingling. Skin warm and dry. No
edema.

Voiding. Voided 350ml clear yellow urine in bedpan

Patient is nervous. Patient repeatedly asks about length of
hospitalization, expected discomfort, and time off
from work.

Breath sounds normal. Breath sounds clear to auscultation all lobes. Chest
expansion symmetrical-no cough. Nail beds pink.

Bowel sound normal. Bowel sound present in all quadrants-abdomen
flat. BPO since 12:01 a.m.

Ate well. Ate all of soft diet served during lunch.

Lippincott William & Wilkins 2009, Evidenced-Based Nursing Guides to Legal and professional Issues ( pp:291)