The subjective section of your documentation should include how the patient is currently feeling and how they’ve been since the last review in their own words.
So as part of your assessment you may ask:
“How are you today?”
“How have you been since the last time I saw you?”
“Have you currently got any troublesome symptoms?”
“How has the nausea been?” (or any other relevant symptom)
If the patient mentions multiple symptoms you should explore each of them, having the patient describe them in their own words.
You should document the patient’s responses accurately and use quotation marks if you are directly quoting something the patient has said.
This section needs to include your objective observations, which are things you can measure, see, hear, feel or smell.
Patient’s appearance (e.g. “Patient appears very pale and in discomfort“)
Basic observations (vital signs):
Oxygen saturations (including the amount of oxygen the patient is receiving if relevant)
Temperature (including any recent fevers)
Fluid balance (fluids going in and coming out):
Drain output / stoma output
Clinical examination findings:
“Widespread expiratory wheeze on auscultation of the chest”
“Abdomen soft and non-tender”
“No cranial nerve deficits”
Other investigation results:
Recent lab results (e.g. bloods/microbiology)
Imaging results (e.g. chest x-ray/CT abdomen)
The assessment section is where you write your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections.
Summarise the salient points:
Productive cough (green sputum)
Increasing shortness of breath
Tachypnea (respiratory rate 22) and hypoxia (O2 saturations 87% on air)