looking for template

Published

Specializes in med surg.

I am looking for a careplan template and have not found one yet.

Any one have one they care to share?

There are any number of care plan books out there. Go to the bookstore (online or hard-copy) or the library and look over a few if your faculty hasn't assigned you one or hasn't given you a template they want you to follow. Ask them, too.

The basic elements are:

Subjective: What does the patient tell you about what's happening?

Objective: What are your observations/chart findings/measurements that relate to the possible problem?

Assessment: What do you think is going on and why? (That's your nursing diagnosis with rationales)

Plan: What are your nursing interventions going to be, and how will you reassess how they work?

Another way to look at this is ADPIE: Assessment, Diagnosis, Plan, Intervention, Evaluation, which would include all of the above

This is the one we are supposed to use for 1 of my instructors.

care plan template.docx

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