What does 'objective' information consist of during a patient visit?

Objective information during a patient visit refers to data that can be observed, measured, or quantified, rather than subjective experiences or opinions. Observations made by the medical assistant and exam findings fall under this category because they are based on factual and verifiable evidence. This includes results from physical examinations, laboratory tests, imaging studies, and any measurable information that can contribute to the assessment of the patient’s condition.

While personal opinions, feelings about treatment, and general notes on behavior can provide context and insight into the patient's experience, they do not constitute objective data. Hence, the emphasis on observables ensures that the information collected during a medical visit is reliable for clinical decision-making and patient care planning.