What should be included in an objective note regarding a patient's evaluation?

In an objective note concerning a patient's evaluation, information should be strictly factual and observable. Including details such as positioning, assistive devices, the environment, and the level of assistance provided offers a clear picture of the patient's current condition and needs. This type of information is essential for healthcare professionals to assess the patient's functional status and make informed decisions about their ongoing care.

By documenting these objective findings, the healthcare provider creates a reliable record that can be reviewed by other team members or used in future evaluations. This differs from subjective notes, where personal opinions, beliefs, or interpretations might be included.

While the patient's medical history and treatment outcomes from previous sessions are important for understanding the overall context of the patient's care, they are not categorized as objective observations from the current evaluation but more as background information. Therefore, focusing on concrete observations related to the patient's immediate situation aligns best with the goal of objective notes.