NURSING CARE PLAN Document QF-CN-25 Revision 1

Code Number
(NCP)
Effectivity August 17, 2018

NAME/ INITIALS OF PATIENT: _________________________________________________ AGE: ____________ SEX: __________ STATUS: _____________
ADDRESS: _________________________________________________________________ HOSPITAL: _____________________ WARD: _______________
PRINCIPAL MEDICAL DIAGNOSIS: ___________________________________________________________________________________________________
NURSING CARE PLAN DEVSED BY: ___________________________________________________ YEAR AND SECTION: ______________ GROUP__________
SCORING IMPLEMENTATION
CRITERIA VL L H VH
NURSING ORDERS / APPROACHES RATIONALE
Content
Complete
Assessment
Parameters
Nursing
Diagnosis
Short-term
Outcome
Long-term
Outcome
Nursing
Orders
Rationales
Actual
outcome
TOTAL SCORE

VH – Very High
H – High
L – Low
VL – Very Low

Rated by:

Date: __________________
ACTUAL OUTCOME DATE AND TIME RESOLVED
Conforme:

Date: __________________
 NURSING CARE PLAN Document QF-CN-25 Revision 1
(NCP) Code Number
Effectivity August 17, 2018
DATE AND TIME NURSING DIAGNOSIS SHORT – TERM AND LONG – TERM OUTCOMES

ASSESSMET PARAMETERS IMPLEMENTATION

NURSING ORDERS / APPROACHES RATIONALE

ACTUAL OUTCOME DATE AND TIME RESOLVED