NURSING CARE PLAN

Name: Date Admitted:

Age: Chief Complaints:
Sex: Diagnosis:
Civil Status: Attending Physician:
Address: Ward/Area:

ASSESSMENT NURSING BACKGROUND PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE

Subjective Cues: (Problem + Etiology) Literature that Specific Must be based on Justify the Based on the goals
(verbalized by the supports and Measurable the focused interventions and desired
patient) Must be based on explains your Attainable problem and outcomes indicated
assessment nursing diagnosis Realistic etiology
Time-bounded
Independent and
Objective Cues: Based on the dependent
(relevant, diagnosis interventions
measurable and formulated
observable data Within the scope of
that supports the Subject practice of nurses
subjective cues) Verb
Modifier
Criterion

Name:
Age:
Sex:
Civil Status:
Address:
CLIENT IN CONTEXT
Patient History:
(chief complaints, reasons for
admission)
History of Present Illness:
History of present condition
History of Past Illness:
History of other illnesses,
allergies, health related
events/conditions
Socio-economic Status:
employment
Organ Involved:
Actual drawing of organ with
labels
OUTCOME PRESENT STATE TEST
ASSESSMENT
Subjective Cues:
Verbalized by the patient
Objective Cues:
(relevant, measurable and
observable data that
supports the subjective cues)
Nursing Diagnosis:
(Problem + Etiology)
Must be based on
assessment
Date Admitted:
Chief Complaints:
Admitting Diagnosis:
Attending Physician:
Ward/Area:
INTERVENTIONS RATIONALE EVALUATION
Must be based on the Justify the interventions Evaluate the outcome
focused problem and etiology given
Independent and dependent
interventions
Within the scope of practice
of nurses
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0186 Dr. Cecilio Putong Street
Tagbilaran City, Bohol, Philippines
Telefax No. (038)411-3101
www.universityofbohol.com

FDAR CHARTING

Name: _______________________________________ Age: ______________ Sex: ____________ Room/Bed No.: __________________

DATE AND TIME FOCUS PROGRESS NOTES

Date and time of care Problem Focus: Data, Actions, Response:

plan
Nursing Diagnosis Cues (Subjective and Objective)
Event Interventions
Time of every (Admission, Discharge, Pre-Operative Prep) Patient’s Response to Interventions
intervention should be Patient Concern/Event
documented (Vomiting, Coughing, Code Blue)
 HEALTH TEACHING PLAN FORMAT

I. TOPIC : ___________________________________________________________

II. RATIONALE : ___________________________________________________________

III. OBJECTIVES : ___________________________________________________________

IV. HEALTH TEACHING METHOD : ___________________________________________________________

V. TARGET AUDIENCE : ___________________________________________________________

VI. DATE AND TIME : ___________________________________________________________

VII. CONTENT : ___________________________________________________________

VIII. EVALUATION : ___________________________________________________________

IX. PREPARED BY : ___________________________________________________________