NUSING CARE PLAN INSTITUITIONAL GUIDELINES AND FORMAT

Assessment Explanation of the Objective Intervention Rationale Evaluation /Expected

problem outcome
(Narrative form)

S> covert Discuss what caused Goals based on Dx- must be based Scientific Statements stating if
data(symptom) the patient to the nursing on the objectives principles, client met the goals set
develop the problem diagnoses – and subjective theories or for patient or not.
O > overt data (signs, should be concepts Include proposed
observable and Discuss and explain “S-M-A-R-T” Tx – independent underlying modifications or present
measurable) the facts in the case Dependent nursing plan for improvement of
and cites related Short term Collaborative/ intervention nursing care.
A> Your Nursing knowledge from objective Supportive
Diagnosis that best readings, research
describes the problem and related learning Long term Edx – based on the
being identified experiences related objective nursing assessment
to the nursing
problems identified.

Include your
References/source

*Actual NCP- stated in past tense *Potential NCP – stated in future tense
Last column – “evaluation” last column – “expected outcome”

NUSING CARE PLAN INSTITUITIONAL GUIDELINES AND FORMAT