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Discussion

subjective versus objective data

Hi, I just have a simple question: If I were to write the pt's subjective data in "" marks, but I paraphrased and it was obvious that I paraphrased, would that be wrong?

Ex:

The pt is afraid of the dark and must have a light on at all times.

Subjective documentation:

a.) Pt AAO X 4, sitting with erect posture. "he is scared of the dark and says that he needs a night light." Reassurance given. Small light obtained from management, and after given to the pt, anxiety subsided.

b.) Pt AAO X 4, sitting with erect posture. "I need a night light. I am scared of the dark." Reassurance given. Small light obtained from management, and after given to the pt, anxiety subsided.

In example "a," I paraphrased. Is this wrong?

Thanks!

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    • Featured Replies

    I would say:

    Pt AAO X 4, sitting with erect posture. Pt states he is scared of the dark and says that he needs a night light.

    This way, it's clear that I'm not trying to directly quote the patient but am describing what I heard him say.

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    You might put it like this instead...

    a.) Pt AAO X 4, sitting with erect posture. Pt states he is "scared of the dark" and that he "needs a night light." Reassurance given. Small light obtained from management, and after given to the pt, anxiety subsided.

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    • Experts

    Only put quotation marks around what a patient actually says. It is up to the reader to determine what is subjective and objective.

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    I agree with Daytonite, only the pt's. statement goes in quotes.

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    Please tell me you work on a pediatric unit :)

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    I would write option B.

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    You can either paraphrase or direct quote him, but A is wrong because you can't just paraphrase and put it in quotes as if it's a direct quote.

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