Choose Signs and Symptoms That Prove the Problem

Symptoms are reported; signs are observed or measured

Signs and symptoms are the defining characteristics that demonstrate a nutrition problem. A symptom is experienced and reported by the person or a proxy, such as nausea, early satiety, pain with swallowing, or fatigue. A sign is observed or measured, such as documented meal completion, a verified weight trend, loss of muscle on a nutrition focused physical examination, a laboratory result, or an instrumental swallowing finding. Subjective does not mean unimportant, and objective does not mean automatically valid. A detailed patient report can be highly relevant, while a measured value can be distorted by fluid status, timing, technique, inflammation, or equipment. Record the source, method, date, and time frame. If a caregiver reports intake or a nurse documents emesis, identify that source. This makes the evidence auditable and helps the next RDN compare like with like.