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NURSING PROCESS CARE PLAN FORMAT EVALUATION
PATIENT’S INITIALS: STUDENT’S NAME:
DATES OF CARE:
ASSESSMENT
ANALYSIS
PLANNING
IMPLEMENTATION
EVALUATION
SUPPORTIVE
DATA
----------------------------------
S. What the client says
about this problem
O. What you observe:
see, hear, feel, smell,
and measure
+
Client lab values, test
results
+
Medications
+
Doctor’s diagnosis
From this data, the reader
must be able to tell that
he/she really has a problem
NURSING
DIAGNOSIS
------------------------------
Statement of Problem
(Nursing diagnosis
[NANDA List] plus
etiology)
NOT doctor’s diagnosis
Only one diagnosis per
page
PATIENT GOALS/
OUTCOME
CRITERIA
--------------------------------
Goal Statement
Outcome criteria define
goals. They define what
will be observed when
goal is met
Provide time frame
Are measurable
Both goals and outcome
criteria stated as
behavioral objective
NURSING
ACTIONS
--------------------------------
Actions to relieve problem
and help client achieve
goal (use textbooks)
Each must be specific and
complete statements,
including who, what,
where, when, how, how
long, and how often, etc.
Label:
I/Independent actions
nurses can do without
doctor’s order
D/Dependent – what the
doctor orders for this
problem
C/Collaborative – require
knowledge, skill, and
expertise of another health
care professional
SCIENTIFIC
PRINCIPLES/
RATIONALE
---------------------------------
Tells why each action
should help achieve the
goal
Must have statement for
each action
OBSERVATIONS/
CONCLUSIONS
--------------------------------
Have goals been partially
or fully met?
Describe in terms of the
outcome criteria
Should plan be revised or
continued?
