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UCQ

Nursing Charting and Documentation

Using Objective Language

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