Objective vs. Subjective data (again)

This kind of seems like splitting hairs, but having heard about a patient calling 911 saying she has a temp of 107 and has been to Africa in the last month in order to get an ambulance to her home faster (only to have hazmat teams arrive and find she was lying 100%), you CANNOT take what a patient says about these things at face value, AND you cannot verify the accuracy of their equipment. I have had patients bring their BP cuff to our clinic to compare their results to what we get, which is good, but even still, one piece of equipment varies from another. I wouldn't document much of anything I or another medical professional didn't obtain on our own as objective.

We usually document info from the patient as "Pt reports/pt states/pt complains of/pt denies" etc.

I was taught objective is what you see pt having chest pain evidenced by grimacing face clutching chest, vomiting, sweating, subjective is pt says they are having chest pain, nauseated

Objective is measurable- fever

Subjective is S/S reported- headache

If the patient takes her temperature in front of you and you see the result, then it is objective data. It is objective because it is observed and measured by you. If the patient reports a temperature reading, then that is SUBJECTIVE to you, because you cannot measure it directly. It is certainly objective data to the patient herself, so if the patient was writing a nursing care plan for themselves, they could list their own temperature measurement as objective.

However, you are right that in the real world objective/subjective are less clear cut. And to be completely honest, the majority of my SOAPs are written as S/O, A and P. SOAP is reserved for when more comprehensive documentation is required, like when I admit someone in labor, am dealing with a new or complex problem, or something like that.

Example:

S/O: Pt reporting increased pressure with contractions and thinks her water broke. Contracting 4 in 10, 50 seconds, moderate intensity by palpation. Pt breathing through UCs, bearing down involuntarily at peak. Cat II FHR with recurrent early decels, normal maternal vitals. SVE 10/100/+1, clear fluid actively leaking from introitus.

A: 2nd stage of labor, reassuring mat/fet status, SROM with clear fluid.

P:

Continue plan of care

Provide hands on labor support

Anticipate SVB

Or whatever. That same pt would have a comprehensive note on admit, if I identified a problem, or when I assumed care.

"in the real world objective/subjective are less clear cut" I was trying to make the opposite case: Objective data is measured (quantitative); Subjective data is qualitative. It's more clear cut because obj/subj is a property of the data that doesn't depend on the ID of the observer. Patient's (or others) lying, using crappy equipment, using poor technique, misreading a measurement can all make the data useless or even detrimental to assessment. That could also happen with nurses' measures (not many, and not we nurses), but it is a different issue.

Anyway, I guess I can think of it as "subjective AND 'reported' or 'indirect' data" and observed/measured data while documenting according to the accepted convention.

I look at it very simply

Subjective is patient Said

Objective is I observed.

Subjective Says

Objective Observed

If I didn't observe it then it needs to go in the said column.