Nursing Process Care Plan Format Evaluation
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3NURSING PROCESS CARE PLAN FORMAT EVALUATION
PATIENT’S INITIALS:
STUDENT’S NAME:
DATES OF CARE:
ASSESSMENT
ANALYSIS
PLANNING
IMPLEMENTATION
EVALUATION
PATIENT GOALS/
SCIENTIFIC
SUPPORTIVE
NURSING
OUTCOME
NURSING
PRINCIPLES/
OBSERVATIONS/
DATA
DIAGNOSIS
CRITERIA
ACTIONS
RATIONALE
CONCLUSIONS
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S. What the client says
Statement of Problem
Goal Statement
Actions to relieve problem
Tells why each action
Have goals been partially
about this problem
and help client achieve
should help achieve the
or fully met?
(Nursing diagnosis
goal (use textbooks)
goal
Outcome criteria define
O. What you observe:
[NANDA List] plus
goals. They define what
Describe in terms of the
see, hear, feel, smell,
etiology)
Each must be specific and
Must have statement for
will be observed when
outcome criteria
and measure
complete statements,
each action
goal is met
NOT doctor’s diagnosis
including who, what,
where, when, how, how
+
Should plan be revised or
Provide time frame
Only one diagnosis per
long, and how often, etc.
continued?
Client lab values, test
page
results
Label:
Are measurable
I/Independent actions
+
nurses can do without
Both goals and outcome
doctor’s order
criteria stated as
Medications
behavioral objective
D/Dependent – what the
doctor orders for this
+
problem
C/Collaborative – require
Doctor’s diagnosis
knowledge, skill, and
expertise of another health
From this data, the reader
care professional
must be able to tell that
he/she really has a problem
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