What should be documented in shared decision-making?

• A. The agreed-upon plan.
• B. A brief summary of the discussion without specifics.
• C. The caregiver's questions and concerns, but not the plan.
• D. The agreed-upon plan, next steps, and who is responsible for each action.

Answer: (D)

In shared decision-making, the record should capture not just what was decided but how it will be carried out. The best option includes the agreed-upon plan, the next steps to implement it, and who is responsible for each action. This combination creates a clear, actionable roadmap for everyone involved, helps ensure follow-through, and aligns care with the patient’s and caregiver’s values and preferences. It also supports safer, more coordinated care by making accountability explicit.

If you only document the plan, you risk missing concrete steps or who will do them, which can lead to confusion and delays. If you only note a brief summary or the caregiver’s questions without the action plan, there’s no clear guide for implementation. Including all three elements—plan, next steps, and assigned responsibilities—provides a complete record of the shared decision-making process.