Includes subjective, objective and historical data that is related to the Nursing Diagnosis.
Includes appropriate diagnosis for patient that includes all appropriate parts (stem, related to or R/T, and as evidenced by (for actual diagnosis) and is NANDA approved.
This is already completed for you.
Includes data that is listed as criteria in goal statement.
What did you do for your patient related to the nursing intervention?
Includes data that is listed as criteria in goal statement. Based on this data, goal is determined to be met, partially met, or not met.