Which component documents the physical findings and test results?

• A. Objective Information
• B. Subjective Information
• C. Assessment
• D. Plan

Answer: (A)

Physical findings and test results are captured in the objective information portion of a chart. This section includes data obtained by the clinician through the exam and tests—vital signs, physical examination findings, and interpretations or results of studies like imaging or labs. It is about what is observed, measured, or documented by the healthcare provider, not what the patient reports.

For example, you’d see entries like vital signs (BP, pulse, respiratory rate), exam notes (lungs clear, heart sounds normal), and test results (X-ray shows no acute abnormality, troponin negative). In contrast, subjective information covers the patient’s descriptions of symptoms and history (what the patient reports feeling), the assessment contains the clinician’s diagnostic reasoning and conclusions, and the plan outlines the treatment and follow-up steps.