When should outcomes for goals be marked as achieved?

Outcomes for goals should be marked as achieved at the time of discharge or transfer because this represents a critical juncture in the patient’s care continuum. At discharge, a healthcare professional assesses the patient's progress toward meeting the established goals, confirming that the patient has successfully met the objectives set forth in the care plan. This evaluation ensures that the patient is stable and ready for the next phase of care, whether at home or in another facility.

Marking outcomes at discharge also facilitates effective communication among care teams, as it provides a clear summary of the patient’s achievements and ongoing needs. This timing is essential to support the patient's safe transition and ensures continuity of care, as any unachieved goals can be communicated to the next healthcare provider, allowing for appropriate follow-up.

Assessing goals during hospitalization, after follow-up appointments, or whenever the care plan is edited may not accurately reflect the patient's readiness for discharge or readiness to manage at home. These points in time do not necessarily capture the overall progress in the context of the discharge process.