Which items are appropriate for inclusion in objective documentation?

Objective documentation refers to the factual, measurable, and observable information collected during patient assessments or interventions. This often includes numerical data, results from assessments, and other verifiable observations.

Including patient range of motion (ROM) and manual muscle testing (MMT) scores in documentation is appropriate because these are objective measurements that provide quantifiable data about a patient’s physical function. This information can be consistently checked and compared over time, making it essential for monitoring progress, planning treatment, and justifying the need for interventions.

In contrast, patient-reported symptoms, future goals or interventions, and therapist impressions tend to be more subjective. Patient-reported symptoms are based on the individual’s personal experience and cannot be quantified in the same manner as ROM and MMT scores. Future goals or interventions are often based on clinical judgment and therapeutic planning but do not serve as concrete data. Similarly, therapist impressions involve personal evaluation and interpretation, which can vary from one clinician to another and are not strictly quantifiable. This is why they do not fit the criteria for objective documentation.