Objective vs. Subjective data (again)

[combinate]

I did a search and read some but not all of the many discussions. It seems like there is a systemic problem with the use of these terms in nursing:

Objective data is quantitative (and physically observable) subjective data is qualitative. That does not change with the observer. If a patient takes their own blood pressure, measures their temperature, urinates in a graded colander to track output, tracks their fluid input, reports a cough ... ; these are objective data. The accuracy of the data can vary greatly, and it may not be reliable, but that seems to be a different issue.

We record the site/method of temperature measures (oral, tymp, temporal, axial) with the measure itself because they vary. Why not also qualify patients' own temperature measurements accordingly ("Pt. measured" perhaps), but consider them objective? It just seems condescending and erroneous to call patients' measurements and direct observations subjective.

In legal language, don't they call someone else's observations heresay (sp)? Maybe that is appropriate for the purpose of the nursing process. Or maybe the qualifier "not observed" or "from patient" is better.

??

[RunBabyRN]

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.

[nowim clean]

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

[guest769224]

Objective is measurable- fever

Subjective is S/S reported- headache

[cayenne06, MSN, CNM]

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.

[JBudd, MSN]

I agree with Cayenne; if it is data your pt told you, it is subjective because it is "history", you did not actually measure it.

Pt's report all sorts of things, it is all subjective; they can report an earlier fever, but until you take a temperature, and chart it as taken by you, you don't have objective data. Histories are very important, and I am bothered by parents who won't medicate a kid "because I wanted you to see the fever", but that info still goes into the subjective column.

You are partly correct, obj data does not change with the observer, as long as the observer is a health care provider authorized to be charting on that pt. Being an "outsider" (not the pt or pt's family) supposedly makes you more objective as well, in another sense of the word.

[combinate]

"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.

[quixotic.dy]

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.