Includes subjective, objective and historical data that support nursing diagnosis.
Relevant NANDA approved diagnosis written in proper form (includes stem, related to or R/T, and as evidenced or AEB)
Includes patient/ family short term and long term goals based on the nursing diagnosis. Goals must be patient focused, realistic, and have clear measurable criteria with a target date/ time.
Nursing interventions or actions that directly relate to the etiology of the nursing diagnosis and the patient goal and desired outcome. Each intervention must include referenced rationale (including source and page number if applicable).
Outlines the methods to be used in evaluating outcome criteria, expectations for goals being met, and what would determine that the goal is met, partially met, or unmet. Explain how the plan of care would be revised or continued in each case including a new realistic evaluation date/time.