What should be included in a care plan documentation?

In the context of care plan documentation, including patient preferences and goals is crucial as it ensures that the care provided is tailored to the individual needs and desires of the patient. This aspect of the care plan empowers patients by involving them in their own care, taking into account their personal values, cultural background, and specific wishes regarding treatment and outcomes. When patients have a say in their care plan, it fosters a sense of autonomy and can enhance their overall engagement in the healthcare process.

Incorporating patient preferences and goals can also positively impact adherence to treatment plans, as individuals are more likely to follow recommendations that align with their own aspirations and lifestyle. This personalized approach not only improves patient satisfaction but can lead to better health outcomes as care is more effectively aligned with what the patient truly wants.

Other options, such as including only medication details or general information unrelated to care, overlook the necessity of a holistic approach in healthcare. While details about the patient’s history may be important, they serve a different purpose and do not inherently emphasize the patient's active role in their care, which is captured through their preferences and goals.