In an evaluation statement, which element is typically included?

In an evaluation statement, which element is typically included?

• A. Level of goal attainment
• B. Patient's allergies
• C. Date of discharge
• D. Primary diagnosis

Answer: (A)

The main idea being tested is documenting whether patient goals were met. In an evaluation statement, you explain how well the patient achieved the established goals, using objective data and clinical judgment. You indicate the level of attainment—whether the goal was fully achieved, partially achieved, or not achieved—and you support that with concrete evidence from the patient’s status, measurements, or observations. Based on this evaluation, you may decide to continue, modify, or revise the care plan and set the next steps. Other items, like allergies, discharge date, or the primary diagnosis, belong in other parts of the chart and provide context, but they don’t describe progress toward goals themselves.

The main idea being tested is documenting whether patient goals were met. In an evaluation statement, you explain how well the patient achieved the established goals, using objective data and clinical judgment. You indicate the level of attainment—whether the goal was fully achieved, partially achieved, or not achieved—and you support that with concrete evidence from the patient’s status, measurements, or observations. Based on this evaluation, you may decide to continue, modify, or revise the care plan and set the next steps. Other items, like allergies, discharge date, or the primary diagnosis, belong in other parts of the chart and provide context, but they don’t describe progress toward goals themselves.