All of the following must be documented in the patient’s chart when expected outcomes have not been met EXCEPT
a. the actual outcome.
b. who was responsible for the failed outcome.
c. the new or adjusted plan.
d. the reason for the failed outcome.
B: When expected outcomes have not been met, the actual outcome and the plan to correct the situation should be documented in the chart. This may mean making a whole new plan or simply correcting the existing one. In either situation, the chart should continue to follow the patient’s plan as it changes or as the desired outcome is met. It is not necessary to include who was responsible for the failed outcome.