TimelyScholarFree Tools › Nursing Care Plan Template
Build a nursing care plan through the five steps of the nursing process: assessment, diagnosis, planning, implementation and evaluation. Prioritise problems, write measurable goals, add interventions with rationales and download a Word table.
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Do not enter names, dates of birth, record numbers or other identifying details. Care plans for real patients belong in the official record.
The Word file lists problems in priority order, from physiological needs upwards. Your plan is saved in this browser only.
Record subjective and objective data.
Enter each nursing diagnosis, its priority and specific, measurable goals.
List interventions with rationales, then record whether goals were met.
The nursing process, first described by Ida Jean Orlando in 1958, is a systematic approach to patient-centred care in five steps: assessment, diagnosis, planning, implementation and evaluation (ADPIE).
Problems are commonly prioritised using Maslow's hierarchy of needs, with physiological and safety needs first. Goals should be specific, measurable, attainable, realistic and time-bound, and evaluation leads to reassessment and changes to the plan.
Standardised diagnosis labels are published under licence, so enter the approved wording your programme or institution uses.
Explain why each intervention should help and support it with a current, authoritative source such as a clinical guideline.