The Objective Section
The Objective section contains measurable, observable, and verifiable clinical data. Unlike the Subjective section which captures the patient's perspective, the Objective section documents what you and other clinicians can directly observe, measure, and confirm.
Vital Signs Documentation
Vital signs are the foundation of objective data. Document them completely with context:
**Complete vital signs include:**
• Blood Pressure (with position and arm used)
• Heart Rate (and rhythm if irregular)
• Respiratory Rate (and effort)
• Temperature (and route)
• Oxygen Saturation (and supplemental O2 if any)
• Pain Score (0-10 scale)
• Weight (for medication dosing, fluid status)
📋 Vital Signs Example
**Good documentation:** Vitals: BP 142/88 sitting, left arm | HR 88 regular | RR 18 unlabored | Temp 98.6°F oral | SpO2 97% RA | Pain 6/10 **Poor documentation:** Vitals: WNL The good example provides specific values with context. 'WNL' tells the reader nothing and doesn't demonstrate that vitals were actually assessed.
Physical Exam Documentation
Document your physical exam systematically. Include what you assessed, what you found, and pertinent negatives.
**Standard format:**
• **General**: Appearance, distress level, positioning
• **HEENT**: Head, eyes, ears, nose, throat findings
• **Cardiovascular**: Heart sounds, rhythm, pulses, edema
• **Respiratory**: Breath sounds, effort, symmetry
• **Abdomen**: Inspection, auscultation, palpation findings
• **Neurological**: Mental status, cranial nerves, motor, sensory
• **Skin**: Color, temperature, lesions, wounds
• **Musculoskeletal**: ROM, strength, tenderness
Be Specific, Not Vague
Replace vague terms with specific findings:
- •Instead of 'lungs clear' → 'Lungs CTA bilaterally, no wheezes, rhonchi, or rales'
- •Instead of 'heart RRR' → 'Heart regular rate and rhythm, S1/S2 normal, no murmurs, rubs, or gallops'
- •Instead of 'abdomen benign' → 'Abdomen soft, non-tender, non-distended, +BS all quadrants'
- •Instead of 'neuro intact' → 'Alert and oriented x4, CN II-XII intact, strength 5/5 all extremities'
- •Instead of 'skin normal' → 'Skin warm, dry, intact, no rashes or lesions'
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Pertinent Negatives in Objective
Include pertinent negatives that support your differential diagnosis. For a patient with chest pain, document: 'No JVD, no peripheral edema, no calf tenderness.' This shows you assessed for heart failure and DVT/PE.
Lab and Diagnostic Results
Include relevant lab values and diagnostic results in the Objective section:
• Document specific values, not just 'normal' or 'abnormal'
• Flag critical or significantly abnormal values
• Include pending results with 'pending' notation
• Reference previous values for comparison when relevant
**Example:**
Labs: WBC 14.2 (↑), Hgb 12.1, Plt 245, BMP within normal limits, Troponin <0.01 (x2), BNP 89
ECG: Normal sinus rhythm, no ST changes, no Q waves
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Common Objective Mistakes
Avoid these documentation errors: • Including subjective information (patient complaints) in Objective • Using 'WNL' without specifying what was assessed • Documenting exams you didn't perform • Missing critical abnormal findings • Failing to document pertinent negatives • Not including units with lab values • Omitting the time of assessment for critical findings