Nursing Care Plan Template with Examples

Nursing Care Plan Template

This AI-powered Nursing Care Plan (NCP) Template helps nurses document comprehensive care plans for their patients. With Heidi, the AI medical scribe for nurses and clinicians, you can instantly generate nursing care plans that:

• Capture detailed assessment data. Including both subjective and objective findings.
• Identify nursing diagnoses to support planned interventions. 
• Evaluate patient progress and adjust the care plan as needed.
  

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What is a Nursing Care Plan Template?

A nursing care plan or NCP template is a structured format that helps nurses assess patient needs, outline medical interventions, and track patient progress to ensure effective care.

Sometimes called a nursing care plan format template, it’s essential for ensuring organized and consistent care by helping nurses via a guided approach to planning and documentation. Standardized NCPs also improve communication among teams, as well as support compliance with medical and legal standards. 

In this article, we’ll help you understand the nursing process, breakdown the nursing care plan format, tell you about the common mistakes to avoid when writing a nursing care plan, and provide you with customizable, AI-enabled NCP templates you can use to improve your medical practice. 

Understanding the Nursing Care Plan Process: ADPIE

ADPIE stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation; the five phases of the nursing process’s systematic approach to patient care. Through the diligent implementation of ADPIE, nurses can practice efficient, patient-centered care.

Assessment‍

This is the data collection phase where nurses gather both subjective (patient-reported) and objective (measurable) information. Typical assessment tools and methods include physical exams, medical history, vital signs, and patient interviews.

Diagnosis‍

Based on what has been gathered during the assessment phase, nursing diagnoses are outlined in this section. Not to be confused with medical diagnoses which directly identify the patient’s illness, nursing diagnoses focus on how the illness is affecting the patient’s daily life.

For example, if the medical diagnosis is osteoporosis, the nursing diagnosis could be “Risk for falls.” NANDA-I (North American Nursing Diagnosis Association) is a standardized framework commonly used in outlining nursing diagnoses, meant to prevent miscommunication between nurses and other healthcare providers.

‍Planning‍

After diagnosis, nurses set SMART (Specific, Measurable, Achievable, Relevant, Time-bound) goals for patient care. This section should outline bespoke short-term and long-term goals for each patient’s condition. ‍

Implementation‍

In this phase, nurses will implement interventions based on the SMART goals. This includes nursing actions carried out independently e.g., repositioning a bedridden patient, and collaborative interventions e.g., administering medication prescribed by a physician.  ‍

Evaluation‍

In the final phase, nurses study and document patient responses to the interventions to determine if the set goals are being met. If they aren’t or are only partially met, this is also where revisions are made to the care plan to improve results.  

Breaking Down the Nursing Care Plan Format

Two commonly used nursing plan of care templates are the three-column, and the four-column formats. The choice of using one or the other depends on several factors including institutional policies, nursing preferences, and most importantly, patient care complexity. Let’s break down the differences below:

Three-column NCP Template

The three categories covered by this format are the nursing diagnosis (identified health problem), planned interventions (actions taken to address the issue), and evaluation (patient’s response to treatment and progress) respectively. It’s a simple, easy to follow structure ideal for quick documentation in basic care plans. 

Four-column NCP Template

The four-column format is more of an advance care plan template designed to cover greater detail. It outlines the three categories covered in the three-column format, with an extra column dedicated for Goals or Expected Outcomes (SMART objectives for patient improvement). The more detailed four-column format is preferred in educational settings and long-term, complex care planning. 

Which Format Should You Use?

The three-column format is best for quick documentation in fast-paced environments, while the four-column template’s more thorough framework is ideal for complex cases and nursing education. 

How to Write a Nursing Care Plan: Step-by-Step Guide

Below is a detailed guide with examples on how to write for each section of your NCP:

Step 1: Gather Patient Information (Assessment)

Collect both subjective data (patient’s symptoms, complaints, feelings) and objective data (vital signs, lab results, physical exam findings). Additionally, you can use a pain scale and a Glasgow Coma Scale if necessary to further quantify and outline your findings.

Example note: Patient is complaining of chest pain, and shared a history of hypertension. ECG readings are also abnormal. 

Step 2: Identify a Nursing Diagnosis

Use NANDA-I guidelines to communicate patient problems through terminologies utilized by fellow nurses and healthcare providers. Formulate a clear nursing diagnosis by identifying the problem, its cause, and providing supporting evidence.  

Example note: Impaired gas exchange related to fluid buildup in the lungs as evidenced by low oxygen saturation and difficulty breathing.

‍‍Step 3: Set SMART Goals and Expected Outcomes‍

Outlines goals that are specific, measurable, achievable, relevant, and time-bound. Include both short-term and long-term objectives based on the patient’s specific needs; this makes it easier for you to track their progress and determine if the interventions are effective.

Example note: Patient will maintain an oxygen saturation of 95% or higher within 24 hours through oxygen therapy and breathing exercises.

Step 4: Plan and Implement Nursing Interventions

Focus on independent interventions (actions that nurses can perform without the physician’s assistance or guidance), but also include relevant collaborative interventions (treatments that require a physician’s order e.g., giving medication). Make sure to provide an evidence-based rationale for each intervention.

Example note:

Independent: Encourage deep breathing exercises and reposition the patient for easier lung expansion.

Collaborative: Administer prescribed bronchodilators and oxygen therapy.

Step 5: Evaluate and Adjust the Care Plan

In the final section, assess whether the interventions are effective, or look into adjusting goals and interventions if the patient’s condition changes. Ensure that you document the patient’s progress clearly for the next shift or care team to maintain high-quality patient-centered care.

Example note: If the patient’s oxygen saturation remains low, reassess the diagnosis, consider additional interventions, or consult with a respiratory specialist. 

Common Mistakes to Avoid When Writing a Nursing Care Plan

Below are some of the most common mistakes to watch out for to ensure the quality and effectiveness of your care plans:

• Writing a medical diagnosis instead of a nursing diagnosis e.g., pneumonia instead of impaired gas exchange. NCPs should focus on nursing interventions, not medical conditions.
  
• Setting vague or unrealistic goals. Aside from ensuring you set SMART goals, you should avoid writing general statements e.g., improve breathing.
  
• Failing to update the care plan as needed. Regularly evaluate and modify the care plan based on patient progress or changing conditions to ensure continued effectiveness. 

Before Heidi, Dr. Chris Bojrab, president of the India Health Group (IHG) had to choose between writing detailed notes or being completely present with his patient during therapy sessions; either way, one would end up suffering over the other.

"It's improved our clinician-patient experience significantly," Dr. Bojrab said. "It allows me to build a better note but at the same time actually talk to my patient more conversationally, be more present in the moment and still wind up with a good note."

Nursing Care Plan Template Example

Here’s a free sample nursing care plan template in PDF and Google Doc file format:

Shifts can get extremely busy for nurses, and documenting each patient’s nursing care plan adds to an already demanding workload. Thankfully, AI-powered healthcare solutions can now provide a more efficient way to streamline nursing care plan documentation.

Easily Complete Nursing Care Plan Templates with Heidi

Heidi is our high-tech AI medical scribe designed to help you complete your nursing care plans in real-time! With your patient’s permission, simply hit record and let Heidi work alongside you!

Here’s how Heidi helps you create your nursing care plans:

• Transcribe - Open Heidi on your computer or mobile device and press Start. Conduct your assessment as normal and let Heidi capture everything in the background. For specific information that you won’t be verbalized, you can add them later under the context tab so Heidi can consider that information.
  
• Customize - After the session, pick your preferred nursing diagnosis care plan template and watch as Heidi perfectly transcribes the details of your conversation and context notes into the appropriate format!
  
• Transform - After generating your nursing care plan, you can ask Heidi to give additional documentation including progress notes and incident reports if needed. 

Heidi adheres to jurisdiction-specific regulations, ensuring data localization for customers in Australia, Canada, the United States, and the United Kingdom. Read more about our compliance here.

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Free Nursing Care Plan Templates

Nursing Care Plan Example Template

General practitioners can use this comprehensive template to review and update patient care plans, document medical history, medications, immunizations, and ongoing care recommendations.

‍View Template

Blank Nursing Care Plan Template (Three-Column Format)

Nurses can use this AI-enabled NCP note template to effectively document care plans. It’s ideal for capturing detailed nursing diagnoses, expected outcomes, and interventions in a structured manner.

‍View Template‍

Comprehensive Nursing Care Plan Example (Four-Column Format)

This 4-column NCP notes template is an effective tool for comprehensively documenting nursing care plans. Nurses can use this to capture nursing diagnoses in greater detail, set SMART goals for patient recovery, and outline interventions along with the evaluation of patient outcomes.

‍View Template

FAQs About Nursing Care Plan Templates

Why are notes important in a nursing care plan?

Notes for nursing care plans are essential to track patient progress, ensure continuity of care, and maintain clear communication among healthcare personnel. Additionally, a detailed record of assessments, interventions, and responses help nurses and physicians make informed adjustments to care plans as needed.

Can AI-generated nursing care plans be customized for specific patient needs?

Yes! Heidi’s AI-enabled nursing care plan templates can easily be customized to fit each patient’s unique conditions, goals, and required intervention. We’ve designed Heidi to be highly-intuitive and user-friendly so you can adopt the system right away. Check out our guide for note management and customization to get started!

How does an AI medical scribe like Heidi improve the accuracy of nursing documentation?

Heidi transcribes patient interactions in real time, reducing documentation errors and helping nurses stay compliant with relevant industry standards such as HIPAA in the US, GDPR in Europe, and APP in Australia, among others. Most importantly, it allows nurses to focus on patient-centered care rather than paperwork.