What should be documented when a patient-centered plan is agreed upon?

• A. The diagnostic impression only.
• B. The treatment options only.
• C. The prognosis discussed only if asked.
• D. The agreed-upon plan, including goals and patient autonomy preferences.

Answer: (D)

The essential idea is to capture the plan that the patient has agreed to, along with how the patient wants to participate in decisions. Document the agreed-upon plan, including the patient’s stated goals and their preferences for autonomy in decision-making. This shows what outcomes the patient seeks and how involved they want to be in choosing treatments or declining options, and it guides all future care to stay aligned with those values. Simply listing a diagnostic impression or separate treatment options doesn’t reflect the negotiated plan. If prognosis or specific discussions about choices were part of the conversation, they can be noted, but the plan itself—rooted in goals and autonomy preferences—is what should be documented.