Published
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.
sports2245
45 Posts
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.