How to Write a Nursing Care Plan

What Is a Nursing Care Plan?

A nursing care plan or NCP chronicles the patient’s needs, goals, and nursing care approach to meet them throughout the client’s hospital stay. Most US hospitals use digital NCPs integrated into the electronic health record and have standard templates for nurses to fill.

Types of Nursing Care Plans

Most hospitals and care centers have an electronic template for care plans. Still, it is helpful to categorize NCP types. There are two primary categories:

• Informal nursing care plan
• Formal nursing care plan
• Standardized care plan
• Individualized care plan

Informal NCPs exist only in the nurse’s mind, and they don’t hold much weight until they are put on paper or filed electronically, and at that moment, they turn into formal NCPs. The formal care plans are divided into standardized (applicable for the majority of patients and conditions) and individualized care plans (developed for hard patients with a set of unique needs that do not apply to other clients).

NCP Objectives

From the client’s point of view, nursing care plans improve nursing care quality and ensure better healthcare outcomes by establishing and achieving several core objectives:

• Evidence-based nursing care. NCPs promote an evidence-based nursing approach which leads to better care outcomes.
• Consistent care quality. Care plans establish a routine that helps clients feel comfortable and familiar with a nursing care approach throughout different hospital stays.
• Patient involvement in care outcomes. NCPs promote communication between the nurse and the client and allow the patient to prioritize their healthcare needs and influence care goals. 

Purposes of a Nursing Care Plan

While NCP objectives cover the client’s needs, overarching purposes of the care plans become evident on a hospital-wide scale and include:

1. Individualized, patient-centric care. NCP helps establish client-specific needs and address them to achieve the best outcomes.
2. Continuous, holistic care. Careful documentation ensures the patient receives the best care regardless of the personnel involved.
3. Liability management. Documenting every assessment, goal, and intervention provides protection for medical staff in case of charges pressed.
4. Quality assurance. NCP analysis can highlight the bottlenecks and weak spots in nursing care to be mitigated to boost client satisfaction rate.
5. Asset management. Care plans highlight a patient’s specific needs that may require a particular skill set, affecting the nursing staff’s scheduling and management.
6. Reimbursement documentation. Hospital administration can use NCPs to prove healthcare services provided to receive reimbursement from insurance companies.

Components, Format, and Structure

Most hospitals develop a printed or digital nursing care plan template for internal use, and while the form may differ, the basics remain the same across the board. A traditional nursing care plan looks like a table with three, four, or five columns. 

• The 3-column NCP includes nursing diagnosis, goals & evaluation, and interventions. The middle column looks like a checklist, where achieved healthcare goals are checked.
• The 4-column NCP template includes nursing diagnosis, goals, interventions, and evaluation. This approach is less efficient, as the second and fourth columns usually look similar.
• The 5-column NCP is reserved for nursing students, who add the rationale column to the 4-column care plan by explaining every step of their thinking when developing the plan. 

Sometimes you may be required to add an Assessment column on the left of the NCP template to include objective and subjective data collected.

Below you’ll find a couple of nursing care plan examples for 3-column, 4-column, and 5-column NCPs.

Student Care Plans Format

It may come as a surprise for nursing students learning how to do a care plan, but their NCPs are much more detailed and complex than those used in hospitals. There is always an additional column present for rationale where students explain why they chose particular interventions for addressing specific nursing diagnoses. 

Professors require nursing students to provide as much info on the care plan as possible to help students get into the habit of evidence-based problem-solving while keeping the patient’s needs their main focus. So while NCPs may seem like the dullest and most useless assignment now, you will thank your professors once you land your first job as a nurse.

Nursing Intervention Types

When planning and writing nursing interventions, remember there are three types:

• Independent interventions. Some are standard and must be performed during every shift (assessing health monitors). Others a nurse can prescribe within the limits of their license (taking blood pressure or sugar level).
• Dependent interventions. You need a doctor to prescribe or supervise these interventions, such as administering medication, inserting a catheter, etc. 
• Collaborative interventions. These call for a referral or assistance by a fellow medical professional, such as a nutritionist or a therapist, who can recommend further interventions or treatment alterations. 

Unless you’re only using independent interventions, you need to include the names of anyone involved in the process, including doctors, fellow nurses, consultants, etc.

3 Questions to Ask Yourself Before Writing a Nursing Care Plan

Before we get into the mechanics of filling in an NCP, you need to make sense of the situation. If you ever get overwhelmed, remember to ask yourself three simple questions, and you’ll write a perfect nursing care plan every time.

What Is Your Patient Suffering From? 

In other words, what is the problem or risk your patient is facing? What makes them feel uncomfortable or annoyed? Answering these questions will help you identify the initial problem and formulate the nursing diagnosis.

Why Is Your Patient Suffering?

In other words, what are the causes of your patient’s problems? That’s where your pathophysiology classes will come in handy and help you locate the root of all issues. If you’re working on student NCPs, answering these questions will help you figure out the rationale.

How Are You Going to Make It Better?

In other words, what can you do to solve the patient’s problem? These are the solutions you can come up with and implement, and they will go into the interventions section of your NCP. Remember that consulting a doctor or referring a patient to a therapist are also considered interventions.

How to Write a Nursing Care Plan

Step 1. Collect Information

Talk to your patient or their family members or caretakers to collect subjective data, like pain level or discomfort. And then use a visual inspection, health monitor data, lab test results, and other hard data to use as objective data about the patient’s condition.

Step 2. Analyze the Data Collected

Raw data doesn’t mean anything until you filter out parameters within the norm and collate subjective and objective data. You need to put the disparate puzzle pieces into a full picture that will help you identify the diagnosis.

Step 3. Develop a Nursing Diagnosis

Unlike a medical diagnosis, a nursing diagnosis is usually small-scale and falls within the standardized categories. Depending on your nursing school or job standards, you may use NANDA-I, NIC, or NOC terms. Do not think up your own diagnosis; it may lead to miscommunication, while standard nursing language minimizes misunderstandings.

Step 4. Establish Care Priorities

If the patient suffers from several issues, you need to prioritize physical needs over safety and security requirements, which come before emotional and self-esteem issues, according to Maslow’s classification of human needs. So alleviating pain should be more important than addressing your patient’s insecurity.

Step 5. Identify Desired Healthcare Goals

Each goal should follow the SMART formula and be specific, measurable, achievable, results-oriented, and timely. Start with “The client will” and include a detailed description of what you wish to achieve. Ideally, you want to engage the patient in establishing the care goals to give them some control and confidence over their healthcare outcomes. Depending on the condition and duration of the hospital stay, you may need to establish short-term and long-term goals and a discharge plan. 

Step 6. Select Nursing Interventions

With your diagnosis and goals in mind, you can choose appropriate interventions to alleviate the patient’s issues and help them achieve their healthcare goals. As we’ve covered before in our guide on how to write a nursing care plan, some interventions may be independent, while others will need to be dependent or collaborative.

Step 7. Explain the Rationale Behind Your Choices

This step is only present in student NCPs, as registered nurses no longer have to provide a rationale for their every action or choice. Nursing school professors use rationale to evaluate your caretaking approach and nursing writing skills, so you need to make it detailed and be precise in your wording when explaining your reasoning.

Step 8. Evaluate the Intervention Outcomes

Ongoing, regular evaluation is a critical step of the nursing process, as it helps you decide whether the interventions are effective or need to be updated or altered. A repeat assessment of subjective and objective data is necessary to decide whether the healthcare goals are achieved. 

Step 9. Formalize the NCP

Starting the nursing care plan and updating it should be second nature once you get into the routine. In most cases, you won’t be able to complete the NCP in one go, as evaluation sometimes needs to take place a few hours or days after the intervention. Still, putting your assessment, goals, and interventions on paper asap is a good habit to develop, and completing the NCP the moment the evaluation is done is equally so.

Things to Avoid When Writing a Nursing Plan of Care

Now that you know how to write a plan of care, let's talk about the common mistakes nursing students and entry-level nurses make when working on their NCPs. The sooner you learn to avoid these pitfalls, the sooner your care plans will become flawless.

When writing an NCP, DO NOT:

• Overuse abbreviations and jargon. Remember, an NCP is meant to make communication among medical personnel easier, so only use easily discernible acronyms and abbreviations that do not have alternative meanings.
• Set vague healthcare goals. It’s not enough to hope the patient will be feeling better; instead, set the goal to lower the pain levels from 7 to 2 on a subjective assessment scale. Every outcome should be measurable; otherwise, you won’t know when it is achieved.
• Leave out third parties involved in the patient’s care. Include the names and positions of any colleague you engage in assessment, intervention, or evaluation.
• Fall behind on your nurse plans. Getting things filed fast will help you remember all pertinent details and make your NCPs accurate, which is always a plus.
• Use chicken scratch in handwritten NCPs. You are not the only person reading your care plans, so make sure your handwriting is legible if the digital filing system is down or unavailable.