Shadow Health Documentation: How to Document Your Assessment (Subjective vs Objective Data and Examples)
9 min read In this guide
- What Shadow Health looks for in documentation
- Shadow Health subjective data vs objective data, with a sorting exercise
- Rules and phrases for professional documentation
- Normal and abnormal documentation examples for every major body system
- A full practice case documented from start to finish
- Common mistakes and FAQs
Why documentation matters
In Shadow Health, documentation is where you show that you understood what you found. In real practice, it is a legal record, a communication tool for the whole team and the baseline for detecting changes in a patient’s condition. Good documentation is accurate, complete, concise, objective and timely (Jarvis & Eckhardt, 2024). After you submit, Shadow Health typically shows model documentation so you can compare your note and improve. This guide explains how to document your assessment in a way that earns credit and prepares you for clinical practice. For an overview of DCE scoring and the Lab Pass, see our Shadow Health DCE: Complete Student Guide.
Shadow Health subjective data vs objective data
Every note starts by putting each piece of information in the right place.
| Subjective data | Objective data |
|---|---|
| What the patient (or caregiver) says: symptoms, history, feelings, concerns | What you observe, measure, hear, feel or see in test results |
| “Reports,” “states,” “describes,” “denies” | Measurements and exam findings |
| Pain rated 7/10; “I feel dizzy”; smokes 1 pack/day; allergic to penicillin (rash) | BP 150/92; grimacing; crackles in bilateral bases; 2+ pitting edema; alert and oriented ×4 |
Quick sorting exercise
Decide whether each finding is subjective (S) or objective (O). Answers follow.
- “My knee aches when I climb stairs.”
- Right knee crepitus with flexion.
- Patient reports nausea since yesterday.
- Temperature 100.8°F.
- Patient is grimacing and guarding the abdomen.
- Denies chest pain.
- Wheezes in both lower lobes.
- Mother states the child has had three wet diapers today.
Answers: 1 S, 2 O, 3 S, 4 O, 5 O (observed behavior), 6 S (a pertinent negative), 7 O, 8 S (caregiver report).
Documentation rules that earn credit
- Separate subjective and objective data into clear sections.
- Be specific and measurable: location, size, color, grade, number and duration.
- Include pertinent positives and negatives, meaning the symptoms the patient has and the important symptoms they deny.
- Use standard terminology and approved abbreviations, such as PERRLA, CN II–XII, ROM and DTRs; avoid unapproved or confusing abbreviations.
- Stay objective: describe behavior rather than labels (“states she has not taken her medication for 2 weeks” rather than “noncompliant”).
- Quote the patient when their words are important, such as the chief complaint.
- Document what you did and to whom you reported abnormal findings.
- Write in your own words. Never copy the model documentation or another student’s note.
Helpful phrases
| Instead of… | Write… |
|---|---|
| Lungs good | Lungs clear to auscultation bilaterally; no crackles, wheezes or rhonchi |
| Heart normal | S1, S2 present; regular rate and rhythm; no murmurs, gallops or rubs |
| Belly soft | Abdomen soft, nondistended; bowel sounds active × 4 quadrants; nontender to light and deep palpation |
| Weak leg | Right lower extremity strength 3/5; left 5/5 |
| Neuro intact | Alert and oriented ×4; CN II–XII intact; strength 5/5 throughout; sensation intact to light touch; DTRs 2+ and symmetric |
| Swollen ankles | 2+ pitting edema bilateral ankles |
| Bad pain | Reports sharp RLQ pain, 8/10, constant × 12 hours, worse with movement |
Documentation formats
- Subjective and objective sections (used in most Shadow Health health assessment exams)
- SOAP notes: Subjective, Objective, Assessment, Plan; common in graduate and nurse practitioner courses
- SBAR: Situation, Background, Assessment, Recommendation; used when reporting to a provider
- Head-to-toe narrative or system-based charting in hospital records
For SOAP notes and care plans, see our guide to SOAP notes, care plans and concept maps.
System-by-system documentation examples
| System | Normal example | Abnormal example |
|---|---|---|
| General | Alert, well-groomed adult in no acute distress | Appears anxious and diaphoretic, sitting upright, speaking in short phrases |
| Vital signs | BP 118/76, HR 72 regular, RR 16, T 98.6°F, SpO2 98% on room air, pain 0/10 | BP 162/98, HR 112 irregular, RR 26, T 101.4°F, SpO2 89% on room air, pain 7/10 |
| Skin | Warm, dry, intact; color appropriate for ethnicity; no lesions; turgor brisk | Pale, cool, clammy; 2 cm stage 2 pressure injury over sacrum with pink wound bed |
| HEENT | Normocephalic; PERRLA; TMs pearly gray with landmarks visible; oral mucosa pink, moist | Right TM red and bulging; tonsils 3+ with white exudate |
| Respiratory | Respirations even, unlabored; lungs clear to auscultation bilaterally | Accessory muscle use; crackles in right lower lobe; dullness to percussion RLL |
| Cardiovascular | S1, S2 present, regular; no murmurs; pulses 2+ bilaterally; capillary refill <3 seconds; no edema | Irregularly irregular rhythm; grade 2/6 systolic murmur at apex; 2+ pitting edema bilateral ankles; JVD present |
| Abdomen | Soft, nondistended; bowel sounds active × 4; nontender; no organomegaly | Distended, tympanic; hypoactive bowel sounds; RLQ tenderness with rebound and guarding |
| Musculoskeletal | Full ROM all joints; strength 5/5 throughout; gait steady | Right knee crepitus and effusion; flexion limited to about 110° with pain; quadriceps 4/5; antalgic gait |
| Neurological | A&O ×4; CN II–XII intact; sensation intact; DTRs 2+; Romberg negative | Left facial droop; left arm drift; slurred speech; decreased sensation left arm |
| Psychosocial | Mood “good”; affect congruent; denies SI/HI | Mood “hopeless”; flat affect; reports passive suicidal thoughts without plan; provider notified |
What to emphasize by Shadow Health exam type
| Exam | Documentation must include |
|---|---|
| Health history | Chief complaint, HPI, past medical and surgical history, medications with doses, allergies with reactions, family history, social history, review of systems |
| HEENT | Head, eyes (acuity, pupils, EOMs, fundi), ears (canals, TMs, hearing), nose, sinuses, mouth, throat, neck, lymph nodes, thyroid |
| Respiratory | Rate, effort, chest shape, expansion, fremitus, percussion notes, breath sounds and adventitious sounds by location |
| Cardiovascular | Heart sounds at five areas, rhythm, murmurs, JVD, pulses graded and compared, capillary refill, edema graded |
| Abdominal | Inspection, bowel sounds × 4 quadrants, percussion, palpation findings, special signs, CVA tenderness |
| Musculoskeletal | Joint inspection and palpation, ROM by joint, strength 0–5 by muscle group, gait, spine |
| Neurological | Mental status, CN II–XII, motor, sensory modalities, DTRs graded, cerebellar tests, gait |
| Focused exams | Detailed OLDCARTS for the complaint, red-flag screening, targeted system findings, reporting and teaching |
Practice case documented from start to finish
Original practice case for learning; not taken from Shadow Health and not an answer key.
Scenario: Linda Grant, 72, comes to the clinic saying, “My ankles are swollen and I get out of breath at night.” She has a history of hypertension and a heart attack five years ago. She has gained 5 pounds in a week, sleeps on three pillows, wakes up short of breath, and admits she has been eating more canned soup and has “run out” of her water pill. On exam you find BP 154/92, HR 98, RR 22, SpO2 92%, crackles in both lung bases, JVD at 45 degrees, an S3 and 2+ pitting edema of both ankles.
Sample documentation
Chief complaint: “My ankles are swollen and I get out of breath at night.”
Subjective: 72-year-old female reports bilateral ankle swelling and dyspnea × 1 week, with 5-lb weight gain over the same period. Reports orthopnea (sleeps on 3 pillows) and paroxysmal nocturnal dyspnea. History of hypertension and MI 5 years ago. States she ran out of furosemide about 1 week ago and has increased intake of canned soups. Denies chest pain, palpitations, fever or cough with sputum.
Objective: BP 154/92, HR 98 regular, RR 22, T 98.4°F, SpO2 92% on room air; weight 5 lb above last recorded clinic weight. Mild dyspnea with conversation. JVD present at 45°. S1, S2 present with S3; no murmurs. Fine crackles bilateral lung bases. 2+ pitting edema bilateral ankles; pedal pulses 2+. Findings reported to provider.
SBAR to provider (example): S: 72-year-old female with worsening dyspnea and edema. B: history of MI and hypertension; out of diuretic × 1 week; high-sodium diet. A: weight gain 5 lb, orthopnea, crackles, JVD, S3, SpO2 92%; concern for heart failure exacerbation. R: request evaluation today and orders for diuretic and further assessment.
Common documentation mistakes
- Mixing subjective and objective data
- Vague words such as “normal,” “good,” “fine” or “WNL” without detail
- Missing pertinent negatives
- Not quantifying findings (pain scores, edema grades, strength grades, measurements)
- Judgmental language or opinions
- Copying the model documentation, which is an academic integrity violation and prevents learning
- Forgetting to document reporting of abnormal findings
Documenting pain, education and empathy
- Pain: location, quality, intensity on a validated scale, onset, duration, aggravating and relieving factors, and effect on function, for example “reports dull low back pain 5/10, worse with sitting, relieved by walking and ibuprofen 400 mg; interferes with sleep.”
- Education: what you taught, how, and the patient’s response, for example “Educated on inhaler technique using demonstration; patient returned demonstration correctly and verbalized understanding of when to use rescue inhaler.”
- Psychosocial and empathy: the patient’s concerns in their own words and how you responded, for example “Patient states, ‘I’m scared it’s cancer.’ Concerns acknowledged; explained next steps in evaluation.”
- Reporting: “Provider notified of BP 168/104 and new headache at 1430; awaiting orders.”
Before-and-after documentation example
| Weak note | Strong note |
|---|---|
| Pt has cough and is SOB. Lungs bad. Smoker. Given education. | Reports productive cough with yellow sputum × 5 days and dyspnea on exertion; 30 pack-year smoking history, currently smoking 1 pack/day. RR 22, SpO2 93% on room air. Crackles right lower lobe; dullness to percussion RLL. Educated on smoking cessation resources; patient states he is “ready to cut down.” Findings reported to provider. |
Documentation checklist
- Chief complaint in the patient’s words
- Subjective data separated from objective data
- OLDCARTS details for every symptom
- Pertinent positives and negatives
- Complete vital signs with units
- Each system examined, with specific, measurable findings
- Pain, education and the patient’s response
- Abnormal findings reported, to whom and when
- Your own words; no copying
Frequently asked questions
Can I use abbreviations in Shadow Health documentation?
Use common, standard medical abbreviations such as BP, HR, PERRLA and ROM, and avoid abbreviations on safety “do not use” lists or ones your course does not accept. When in doubt, write it out.
Should documentation include my interpretation?
In basic health assessment notes, focus on subjective and objective data. In SOAP notes, interpretation belongs in the Assessment section. Avoid putting opinions into the objective section.
How long should my Shadow Health documentation be?
Long enough to be complete, short enough to be readable. Use concise phrases rather than full paragraphs, and include every relevant finding and pertinent negative.
What does WNL mean, and should I use it?
WNL stands for “within normal limits.” Many instructors discourage it because it does not describe what was assessed. Write the specific normal findings instead.
Do I document findings I did not assess?
No. Document only what you actually assessed. If something was not assessed, either leave it out or state that it was deferred, depending on your course’s expectations.
For a deeper look at the two data types, see Subjective vs. Objective Nursing Data: Key Differences, Examples, and Documentation Tips.
More in the series: Shadow Health Focused Exam: Chest Pain, How to Document a Musculoskeletal Assessment, How to Document a Neurological Assessment and How to Write a Shadow Health Reflection.
References
Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.
