In the context of medical records, what does the term "objective" refer to?

The term "objective" in the context of medical records refers to fact-based data that is gathered through examinations and diagnostic tests. This involves measurable and observable findings, such as vital signs, laboratory results, and imaging studies. These are components of the medical record that provide concrete evidence about a patient's health status, rather than interpretations or assumptions.

This factual information is vital because it forms the basis for clinical decisions, treatment plans, and ongoing patient management. In contrast to subjective information, which includes personal opinions or feelings of the provider or patient, objective data is standardized and can be replicated, making it essential for maintaining accuracy and consistency in medical documentation.