Which type of documentation is based on facts and observations and is designed to be as accurate as possible?

• A. Subjective documentation
• B. Objective documentation
• C. Associated symptoms
• D. Pertinent negatives

Answer: (B)

Objective documentation focuses on facts and observations that can be verified by anyone reviewing the chart. It includes measurable data like vital signs, physical exam findings, and test results, as well as observable conditions such as skin color or level of consciousness. Because these data points are observable or quantifiable, they tend to be more accurate and less influenced by personal feelings or bias, which is essential for clear communication, decision-making, and reliable handoffs to other care providers.

Subjective information, by contrast, relies on the patient’s reports—comfort levels, pain, nausea, and other symptoms—which can vary in perception and description. While this subjective data is vital for understanding the patient’s experience, it’s not as inherently verifiable as objective data.