Nursing Care Plan Template

Structured format to organize assessments, diagnoses, interventions, and evaluations.

Name: ____________________________Course: __________________Date: ____________

Patient InformationInitials, age, setting, date. Never include identifying details.

AssessmentSubjective and objective data: history, vitals, labs, observations.

Nursing DiagnosisProblem related to cause as evidenced by signs and symptoms.

Goals & Expected OutcomesSMART: specific, measurable, achievable, relevant, time-bound.

Interventions & RationaleEach intervention paired with an evidence-based rationale.

EvaluationWas each goal met, partially met, or not met? What changes next?