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What goes in a nursing care plan template?

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Quick Answer

A health care professional filling a nursing care plan organizes data into four categories: nursing diagnoses, goals and outcomes, nursing orders and evaluation of the plan, says RN Central. Nursing care plan templates help in the continuity of care and provide direction in the provision of individualized interventions.

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Full Answer

Nursing diagnoses are judgments about the client's responses to health problems and are used to guide the staff in developing the right plan of care, according to RN Central. Unlike medical diagnoses, nursing diagnoses evolve as the client's physical, psychological, spiritual and sociocultural responses change. Depending on the observable client responses, a nurse sets up goals and instructions on how to achieve them. The goals represent a desired change in the client's outcome, while the instructions are the nursing orders.

Nursing orders consist of the date, a descriptive action verb, content of the instruction, and a time element describing the duration or frequency of action. The health care professional carrying out the order must sign the document, explains RN Central. In the evaluation category, the health care professional determines the effectiveness of the nursing care plan and the progress toward goal achievement. The comments in this section help determine whether the nursing interventions should end, change or continue.

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