Nurses' charting and documentation should be objective - free of personal opinions and feelings.
According to the Nova Scotia College of Nursing (2022) - objective data is observed or measured and includes actions and patient responses.
For example:
DO: Objective documentation = BP is.., Patient is cool to the touch. Temperature is... Patient has moderate bleeding from cut... Patient is crying.
DO NOT: Subjective documentation = BP is high. Patient is very cold. Temperature is low. Patient is bleeding alot. Patient is crying too much.
How to avoid subjective writing:
* Do not use superlatives or intensifiers.
* Do not write statements that include what you think or feel about the patient or situation.
Reference
Nova Scotia College of Nursing. (2022, January). Documentation for nurses. https://cdn1.nscn.ca/sites/default/files/documents/resources/DocumentationGuidelines.pdf
