ANSWER
Subjective versus objective data: Presentation outline
First Slide: Title Slide
Title: Objective vs. Subjective Data in Clinical Work
Add your name, background, course, and date.
Slide 2: Subjective Data Definition: Patient Tells You.
For instance: “Every time I eat I feel sick.”
“My throat hurts while swallowing.”
Found in the sections on CC, HPI, allergies, medications, PMH, SH, FMH, Health Maintenance, and ROS.
Subjective data refers to the situation if you must interrogate the patient to gain the response.
Use in clinical settings helps direct additional physical examination and enquiry.
Objective Data Definition: What you find, count, or measure on Slides 3?
For instance, students are PERrlA.
Both sides of lungs are clean.
Patient is AAO x3.
Key Points: Noted in the SOAP note’s Physical Exam part.
Drawn from what you immediately see, hear, touch, or measure.
Fourth slide: a case study overview.
As a new patient, a 65-year-old woman shows up for a standard physical assessment.
Emphasise objective and personal results.
Subjective: Patient describes a lump in her right breast, past of hypertension, family history of stroke and breast cancer.
Goal: BP 120/88; pulse 70 bpm; height 64 inches; weight 125 lbs. Exam results show a regular breathing and heart sounds, pupils 3 mm and reactive to light, and a normal head shape.
Slides 5: SOAP Note Templates
Show how subjective information fits the SOAP note:
Objective:
“Feels a lump in her right breast,” CC says.
HPI: Denies pain; reports the lump has been there one week.
Hypertension, hyperlipidemia, arthritis past medical history.
Lisinopril 20 mg daily; Lipitor 10 mg daily; over-the-counter multivitamins.
Father from stroke; mother from breast cancer.
Social History: Vegan diet, consistent walks, retired software developer.
ROS: Denies SOB, weight loss, stomach ache, fever.
Emphasise in blank the difference between subjective and objective data.
Slides 6: Important Learnings
Subjective data comes straight from the words or answers the patient provides to an enquiry.
Objective Data: Direct physical exam observations or measures.
Soap Note: Subjective results direct your objective test.
Accurate clinical decision-making depends on both kind of facts.
Emphasising the difference between subjective and objective data and their relevance in clinical documentation, this framework succinctly and simply arranges the material.
QUESTION
SUBJECTIVE VS OBJECTIVE DATA
Subjective Data
What the patients TELLS you
“I feel nauseous every time I eat” OR Pt. reports nausea when eating
“My throat hurts when I swallow” OR Pt. reports his throat hurts when he swallows
Subjective data is documented in the CC, HPI, Allergies, Medication, PMH, SH, FMH, Health Maintenance, and Review of Systems sections.
*If you need to ask the pt a question to get and answer it’s SUBJECTIVE DATA
PRESENTATION TITLE
2
Objective DATA
What YOU observe
Pupils are PERRLA
Pt is AAO x3
Lungs are clear
Objective Data is what you would document in the Physical Exam section of the SOAP note.
*If it’s something YOU see, hear, or touch (examine) then it’s OBJECTIVE DATA.
PRESENTATION TITLE
3
CASE STUDY
A 65-year-old female comes to your office for a routine physical examination. She is a new patient to your practice. Does not appear in acute distress, responses are appropriate and appears reliable source. Alert, oriented to person, place, time and situation. Well-nourished, skin warm, dry and intact. States she feels a lump in her rt breast which has been present for 1 week. States lump isn’t painful but is worried because her mom died at age 72 from breast cancer. She states her father died at the age of 83 of a stroke. She has hypertension and takes Lisinopril 20 mg PO daily. She also take Lipitor 10 mg daily for HLD and Multivitamins OTC. She states she is allergic to PCN and gets a rash. She has a 61 yo sister with diabetes and a 60 yo brother with HTN. Her last mammogram was last year and was normal, pap test was 3 years ago, and she is UTD on her colonoscopy. Last tetanus was 5 yrs ago. Denies ever having a dexascan. She is married in a monogamous relationship with her husband. They have 2 children. Her son is 32 without medical problems and her daughter is 28 and has anxiety. She has a master’s degree in software engineering and worked full-time for Microsoft until last month when she retired. She denies any financial stressors. Goes to church every Sunday. She does not smoke, drink alcohol, use any recreational drugs. She walks 3 miles 4 days a week and follows a vegan diet. She denies fever, chills, weight loss or weight gain. On examination her blood pressure is 120/88, pulse is 70 beats/min, respiratory rate is 18. Height is 64 inches and weight is 125lbs. Normocephalic. Pupils size 3 mm, equal and reactive to light. Extraocular eye movements intact to six directions. She denies hearing changes and dizziness. States she used to have migraines which were triggered by stress but hasn’t had any since she retired. Tympanic membranes gray with adequate cone of light bilaterally. Mucous membranes pink and moist. No palpable masses, thyromegaly, lymphadenopathy or JVD. No bruits auscultated. She denies shortness of breath, dyspnea on exertion, swelling or chest pain. She denies abdominal pain, nausea, vomiting or changes in appetite. Denies rashes or bug bites. She does use seatbelts. Denies anxiety or depression. Regular heart rate and rhythm, S1 and S2. Breath sounds clear bilaterally to auscultation. Her abdomen is soft, non-tender, non-distended, normoactive bowel sound. No organomegaly or guarding. Denies numbness or tingling. She reports she has pain and stiffness in her knees in the mornings from her arthritis. Takes Tylenol with some relief.
Everything in red is subjective data
PRESENTATION TITLE
4
NOW- Let’s put all that subjective data into the SOAP NOTE template Notice how the Physical exam section (objective data) is left blank
PRESENTATION TITLE
5
image1.jpeg