Nursing Care Plan Template with Examples

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 gives nurses a guided approach to planning and documentation, supporting organized, consistent care. 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, break down 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 clinical 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 connect 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 Indiana Health Group (IHG), had to choose between writing detailed notes or being fully present with his patient during therapy sessions. Either way, something had to give.

"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."

Shifts can get extremely busy for nurses, and documenting each patient’s nursing care plan adds to an already demanding workload. Thankfully, AI tools can now make nursing care plan documentation faster and less burdensome.

Free Nursing Care Plan Templates