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Uploaded byAIIMS, Rishikesh
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Nursing care plan format

This nursing care plan document contains sections for demographic data, medical history, investigations, medications, nursing care plan, health education provided, and records of nursing notes. The nursing care plan section lists assessment of the patient, nursing diagnoses identified, goals of care, plans for intervention, and rationales. This document aims to comprehensively outline all relevant clinical information and nursing interventions for a patient during their admission and recovery.

Health & Medicine◦
NURSING CARE PLAN Demographic data:Name:Age:Gender:I.P. D No.:Ward:Address:Education:Occupation:Marital status :Religion:Date of admission:Name of the surgery:Type of anesthesia:Allergic to:Date of discharge:Socio economic status:Personal history:Family history :Past medical history and surgical history:Present medical history:Present surgical history:Investigation:S.No. Date Name of investigation Patient’s value Normal value Remarks
Medication:S.No. Name Dose/frequency/route Action Nurse’s responsibility Nursing care plan :Assessment Nursing diagnosis Goal Planning Rationale Implementation Subjective data Objective data Health education:S.No. Date Topic Evaluation
Nurse’s record :Date Recording Signature