Objective vs Subjective Observations

Objective Observations:  Information that can be seen, heard, smelled, felt or measured and confirmed by another person.  Vital signs, a description of urine (including amount, color and clarity) or reporting that your client has a “shuffling gait” are all examples of objective observations.

Subjective Observations:  Pieces of information that cannot be (or were not) observed.  They are based on something reported to you by the client.  For example, your client reports feeling sad or lonely.  You cannot see, hear, smell or feel the feelings yourself. . . and there is no way to measure or confirm the information.  So, you report the client’s exact words in the chart: “Client states, ‘I feel so lonely since my granddaughter went off to college and can’t visit as often.’”

Your documentation or verbal report to the care team should be factual. It should not contain your opinion. Try to use objective information as much as possible.