Nursing Care Plan (NANDA/NIC/NOC)

Patient: [Full name] — [MRN] — [DOB]

Encounter: [Facility] — [Unit] — [Room/Bed]

Care Plan Type: [Initial / Review/Update / Discharge-Transition]

Status: [Active / On Hold / Resolved]

Created: [Date/Time]

Last Reviewed: [Date/Time]

Author: [Name, credentials]

Care Plan Overview

(Limit to 4–6 concise bullets covering essential context for planning.)

• [Primary reason for care or admitting concern]
• [Patient-stated priorities or goals] (Use direct quotes when meaningful; if not yet obtained, document: "Patient goals to be assessed by [timeframe].")
• [Risk flags: falls / pressure injury / aspiration / other] (Include only risks that have been assessed.)
• [Functional baseline and supports: mobility, cognition, caregiver availability]
• [Anticipated discharge disposition] — [Top nursing barriers if known]

Problem Blocks

(Document each nursing problem in its own block. Prioritize: immediate safety/physiologic risk first, then high symptom burden, discharge barriers, and health promotion. Repeat the problem block structure for each additional problem.)

Problem 1: [Problem title] — Priority: [High / Moderate / Low]

Nursing Diagnosis (NANDA-I): [Diagnosis label] ([NANDA code if organizationally required])

• Related to: [etiology/related factors] (For problem-focused diagnoses.)
• As evidenced by: [defining characteristics with timepoints/scores] (For problem-focused diagnoses.)
• Risk factors: [risk factors] (For risk diagnoses only; omit "related to" and "as evidenced by" lines.)

(If diagnosis is not yet validated, document as "Under evaluation" with cues driving concern rather than finalizing the label.)

Outcome (NOC): [NOC outcome label] ([NOC code if organizationally required]) — Timeframe: [target timeframe]

• [Indicator 1] — Baseline: [rating/description] — Target: [rating/description]
• [Indicator 2] — Baseline: [rating/description] — Target: [rating/description]
• [Indicator 3] — Baseline: [rating/description] — Target: [rating/description]

(Use 1–3 measurable indicators. Include patient-centered goal wording when it reflects patient values.)

Interventions (NIC): (List only interventions actually planned. Order by: risk mitigation, monitoring, therapeutic actions, education, discharge coordination.)

• [NIC intervention label] ([NIC code if organizationally required])
  • [Patient-specific activities] — [Frequency/Timing] — [Responsible role: RN / LPN / UAP]
  • Notify criteria: [Safety escalation parameters]
• [NIC intervention label] ([NIC code if organizationally required])
  • [Patient-specific activities] — [Frequency/Timing] — [Responsible role: RN / LPN / UAP]
  • Notify criteria: [Safety escalation parameters]

Rationale: [Brief linkage of interventions to etiology and intended outcomes] (Include only if organizationally required; otherwise omit this field.)

Evaluation: (Complete when plan is reviewed or updated.)

• Evaluated: [Date/Time] by [Evaluator name/role]
• Indicator status: [Current rating/status vs baseline]
• Patient response: [Tolerance, observations, patient report]
• Goal status: [Met / Partially Met / Not Met / Unable to Assess]
• Plan decision: [Continue / Modify / Discontinue / Escalate] (If modified, note changes and rationale. If unable to assess, document reason and next reassessment time.)

Discharge Considerations: (Include when discharge planning is relevant to this problem.)

• [Self-management tasks patient/caregiver must perform]
• [Equipment/supplies needed and arrangements]
• [Referrals/follow-up appointments]
• [Red-flag symptoms and escalation instructions]
• Teach-back results: [Competency verification outcome]

Problem 2: [Problem title] — Priority: [High / Moderate / Low]

Nursing Diagnosis (NANDA-I): [Diagnosis label] ([NANDA code if organizationally required])

• Related to: [etiology/related factors]
• As evidenced by: [defining characteristics with timepoints/scores]

Outcome (NOC): [NOC outcome label] ([NOC code if organizationally required]) — Timeframe: [target timeframe]

• [Indicator 1] — Baseline: [rating] — Target: [rating]
• [Indicator 2] — Baseline: [rating] — Target: [rating]

Interventions (NIC):

• [NIC intervention label]
  • [Activities] — [Frequency/Timing] — [Responsible role]
  • Notify criteria: [Escalation parameters]

Rationale: [If organizationally required]

Evaluation:

• Evaluated: [Date/Time] by [Evaluator]
• Indicator status: [Current vs baseline]
• Patient response: [Observations]
• Goal status: [Met / Partially Met / Not Met / Unable to Assess]
• Plan decision: [Continue / Modify / Discontinue / Escalate]

Discharge Considerations: [As applicable]

Problem 3: [Problem title] — Priority: [High / Moderate / Low]

Nursing Diagnosis (NANDA-I): [Diagnosis label]

• Risk factors: [risk factors for this at-risk diagnosis]

Outcome (NOC): [NOC outcome label] — Timeframe: [target timeframe]

• [Indicator] — Baseline: [rating] — Target: [rating]

Interventions (NIC):

• [NIC intervention label]
  • [Activities] — [Frequency/Timing] — [Responsible role]

Evaluation: [As above]

Discharge Considerations: [As applicable]

Interdisciplinary Coordination

• Team members involved: [Disciplines contributing to plan development]
• Patient/representative participation: [Description of involvement] (If participation not practicable, document reason.)
• Shared goals requiring nursing coordination: [Goals and nursing responsibilities]

Review Schedule

Next Review: [Date/Time] or [Cadence: per shift / daily / weekly / per regulation]

Authentication

Signature: [Author signature] — [Date/Time]

Cosign: [Name/role] (If organizationally required.)

[Attestation statement if required, e.g., "Plan reviewed with patient/representative."]