Subjective vs Objective Assessment

[LittleZee]

Hi all, 

I’m new to the ED and had a general question about your charting. We use EPIC and do focused assessments. There is an option for WDL and it’ll say what is considered “normal” or there is “exceptions” and your chart what the exceptions are. 

My question is, do you consider your patients subjective data when charting your physical assessment as normal? For example, a pt comes in and is complaining of 9/10 stomach pain. This pain is charted in the appropriate “Pain” section (sharp, intermittent, etc) but objectively it is WDL (bowel sounds active, non-distended, no guarding, recent normal BM). So would you still check “WDL” since you didn’t find anything objectively? Or would you put “Exceptions” and state they are complaining of pain? I’ve seen nurses do both. 

Another example, a patient states they feel short of breath, but your respiratory assessment is WDL (RR even, unlabored, saturating 99% room, lung sounds CTAB, NAD..) Would you chart “WDL” or “Exceptions” and comment “Pt reports SOB” but include your normal findings? 

Like I said, I’ve seen nurses do both, but wouldn’t every assessment be an “exception” if we included the subjective info? 

*This is after patients are triaged and complaints on why they came are documented 

This may seem dumb, but I’ve asked a couple of nurses and I don’t seem to get consistent answers. Thanks in advance! 

[Chickenlady]

In your examples, under GI assessment, I don't put WNL, I document that it is not normal and that the pt is complaining of pain.  

For respiratory, again, not normal and there is a box for "dyspena".  The assessments as arranged in Epic include both objective and subjective data. 

[Wuzzie]

If my objective assessment meets the facility guidelines for a "WNL" description then that is what I use.  I will add a comment for patient reported "SOB". Same for abdominal pain in absence of any objective findings. As long as the patient reported symptoms are documented then you have covered all aspects of your assessment.

Personally I think either way is fine. The way I do it just saves documentation time. If I do it the other way then I have to click all the assessment boxes that would have been covered in 1 click if done the other  way. 

[JKL33]

27 minutes ago, Wuzzie said:

If my objective assessment meets the facility guidelines for a "WNL" description then that is what I use.  I will add a comment for patient reported "SOB".

Exact same.

Check WDL and add very brief note: "reports SOB" or "abd pain as noted" [already in pain assessment].

[Corey Narry, MSN, RN, NP]

I feel like physical assessment is your objective examination findings and subjective data is what the patient tells you. It is however rare for a patient to state that they are having abdominal discomfort with no objective physical exam associated with it but I guess those things happen.  I suppose that you can document either way by saying WDL and not even mentioning the subjective complaint OR "double document" by putting subjective data in you objective data.

In medical documentation, we do have to be more specific (even in a focused exam) in saying for example that patient presents with RUQ pain described as constant ache not associated with nausea or vomiting, not induced by meals, no associated constipation...Exam notable for soft, non-distended abdomen with active bowel sounds and no rebound tenderness.  The billers just love seeing all those things in the documentation.

[Wuzzie]

57 minutes ago, juan de la cruz said:

It is however rare for a patient to state that they are having abdominal discomfort with no objective physical exam associated with it but I guess those things happen.

In the ED. Every. Single. Day. 

[JKL33]

6 hours ago, juan de la cruz said:

It is however rare for a patient to state that they are having abdominal discomfort with no objective physical exam associated with it but I guess those things happen. 

I think despite the title, the answer to this question doesn't strictly involve objective vs. subjective.

Whether you check-mark WDL or not has to do with how that particular WDL is defined. People often used to use WNL in times past, now it's WDL and the D stands for defined rather than N for normal (as I'm sure you know...?).

So, if that particular WDL only says the abdomen is soft and bowel sounds are present (for example), then that WDL is met even if the patient reports 20/10 abdominal pain. Most of us feel somewhat weird about marking the WDL in a case like this (even though it is technically met, as defined, and so no "exception" is needed) but we still want to note that there is a problem.

This is what things have come to ??‍♀️. Forget subjective and objective...I'm either checking this box here or some other box somewhere else....?

 

[Kitiger, RN]

34 minutes ago, JKL33 said:

 

Whether you check-mark WDL or not has to do with how that particular WDL is defined. People often used to use WNL in times past, now it's WDL and the D stands for defined rather than N for normal (as I'm sure you know...?).

 

I learned something new today. I had never heard of WDL (Within Defined Limits.) We still use WNL (Within Normal Limits.)

[JKL33]

6 minutes ago, Kitiger said:

We still use WNL (Within Normal Limits.)

The general move to WDL involves the question of what does normal mean; that is to say, what is that particular practitioner intending to document when they say "normal"? Could be anything from "looks like they're breathing just fine" to "all parameters for normal respiratory function known to anyone anywhere, are met."

Whose definition of normal, and under what circumstances?

In EMRs where WDL is used, the limits are defined. The nurse needs to know this definition (or review them and they are usually readily accessible just by hovering or an additional click) and then if the conditions of the definition are met, they check-mark WDL. WDL is met fairly routinely even when there is some sort of abnormality, because the definitions are not meant to be all-inclusive but are very basic.

[Corey Narry, MSN, RN, NP]

@JKL33

Based on your quoted response, I did make an effort to look up nursing assessments on Epic (something us providers never really view at all) and found that it does mix both subjective and objective assessments in one organ system as you stated. 

For instance, GI asked for abdominal inspection, bowel sounds, and presence of tenderness all of which are "objective", then also asked for answer to passing flatus which is "subjective".  Interestingly, the charts I looked at had some of our nurses checking off WDL yet giving exceptions such as abdomen soft, non-tender, etc -- which were all within defined limits. 

I do look at our ICU comprehensive flowsheets like a hawk because that gives me a better picture of drips, hemodynamics, vent settings, fever curve, and I/O's.