looking for template

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