Nursing Care Plan Form

Student Name: Date:

Patient Identifier: Patient Medical Diagnosis:
Nursing Diagnosis (use PES/PE format):
Assessment Data Goals & Outcome Nursing Interventions Rationale Outcome Evaluation &
(Include at least three-five (Two statements are required for (List at least three nursing or (Provide reason why Replanning
subjective and/or objective each nursing diagnosis. Must collaborative interventions with intervention is (Was goal met? How would
pieces of data that lead to the be Patient and/or family rationale for each goal & indicated/therapeutic; provide you revise the plan of care
nursing diagnosis) focused; measurable; time- outcome.) references.) according the patients response
specific; and reasonable.) to current plan ?)

1. Statement #1 1. 1. Outcome #1

2. 2.
2.

3. 3.

3.

Statement #2 1. 1. Outcome #2

2. 2.

3. 3.