Subjective vs Objective

[sports2245]

If a patient was seen in the ER, would that be considered subjective or objective data for SOAPIE documentation? I know that subjective data is normally through pt/family interview but the patient is not able to communicate well & no family members available. Lab or diagnostic test results, if done in the ER, are not in the chart. Thanks in advance for your help.

[adria37]

Subjective is what the patient tells you

Objective is what you observe

Assessment is your diagnosis

Plan is what you will do about it.

For instance:

S- John Doe 46 y/o male, nkma, presents to the ED today for evaluation of aphasia.

then a history of present illness

O- Thin, alert, ambulating with assistance

VS-

labs-

physical exam:

and so on.

[TazziRN, RN]

If the pt cannot talk and there is no family with him, then the sub data would come from whoever brought him in, including paramedics.

[TRINI_RN]

Subjective is also how they feel. For instance:

subjective- headache

objective- facial griamacing, massaging temples

subjective- nausea

objective - 30 cc of emesis

I hope that helps.