Comprehensive Nursing Care Plan and Clinical Documentation Template NURS502

Student

Date

Instructor

Course

Patient Initial

Unit/ Room#

DOB

Code Status

Height/Weight

Allergies

Temp (C/F Site)

Pulse (Site)

Respiration

Pulse Ox (O ₂ Sat)

Blood Pressure

Pain Scale 1-10

Vitals you take at clinical

History of Present Illness including Admission Diagnosis &

Chief Complaint (normal & abnormal) supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

Verbatim- from ED note found under DOC tab on patient dashboard

HPI

Chief Complaint

Admitting diagnosis

Cover all head-to-toe body systems

Focus on body system of admitting diagnosis

Example: Admitting Dx: PNA- course lungs sounds, rhonchi, tachypneic, labored breathing on 2l NC

Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),

include dates and rationales supported with Evidence Based Citations

Past Medical & Surgical History,

Pathophysiology of medical diagnoses

(include dates, if not found state so)

Supported with Evidence Based Citations

Found under Overview tab in the Patient Profile tab

Labs, diagnostics, and procedure directly related to the admitting Dx

Verbatim- from ED note found under DOC tab on patient dashboard

Below and/or within the HPI

Can also be found under the History and Physical doctors note

*Include at least 1-2 paragraphs of pathophysiology and in-text cite

Eriksons Developmental Stage with Rationale

And supported by Evidence Based Citations

Socioeconomic/Cultural/Spiritual Orientation

& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations

1-2 paragraphs of appropriate developmental stage from academic source

In-text cite

List 3 concerns. From academic sourcetextbook

In-text cite

Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each

(At Risk for nursing dx )

Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale

supported with Evidence Based Citations

At Risk forNursing Dx 2 parts required: At risk problem and related to (R/T)

In-text cite from NANDA book or PDF

Located under Orders section within Overview tab under Patient Profile tab

List all current/relevant orders and consults

Priority Nursing Diagnosis

(at least 2)

Written in three part statement

Planning

(outcome/goal)

Measureable goal during your shift

(at least 1 per Nursing diagnosis)

Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching

(at least 4 per goal)

Rationale Each must be

supported with Evidence Based Citations

Evaluation

Goal Met, Partially Met,

or Not Met

& Explanation

Read the blue-colored boxes above each box and follow explicitly

In-text cite

Medications (with APA citations

Class/Purpose

Route

Frequency

Dose (& range)

If out of range, why?

Mechanism of action

Onset of action

Common side effects

Nursing considerations

specific to this patient

Medications you administer and are directly related to the admitting Dx

In-text cite