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Registered Nurse
15-20 minutes

Nursing Care Plan Documentation (Tri-Column Layout)

The NCP Notes (3 Column Format) template by s10.ai is an essential resource for nurses aiming to document nursing care plans with precision and efficiency. This structured format is perfect for detailing nursing diagnoses, anticipated outcomes, and interventions, ensuring comprehensive patient care documentation. By incorporating standardized NANDA-I diagnoses and SMART criteria for outcomes, this template enhances clarity and specificity. It also fosters interdisciplinary collaboration by providing sections for patient education and collaborative interventions. Nursing professionals looking to elevate patient care through thorough planning and assessment will find this template invaluable. Explore the benefits of adopting this tool to streamline your nursing documentation process.

2,503 uses
4.4/5.0
J
Jordan Patel
Template Structure

Organized sections for comprehensive clinical documentation

1. NURSING DIAGNOSIS:
[describe the identified nursing diagnosis]
(Clearly state the nursing diagnosis based on patient assessment. Use standardized NANDA-I nursing diagnoses when applicable. Describe the underlying causes, contributing factors, and defining characteristics that justify the diagnosis. Ensure clarity and specificity.)
Supporting Data:
- [Objective data] (List observable and measurable findings such as vital signs, lab results, physical assessment observations, or diagnostic reports.)
- [Subjective data] (Include the patient’s reported symptoms, concerns, or statements relevant to the diagnosis.)
2. OUTCOMES & EVALUATION:
[describe the expected outcomes and how the patient’s progress will be evaluated]
(Define expected improvements in the patient’s condition based on the nursing interventions. Use specific, measurable, attainable, relevant, and time-bound (SMART) criteria.)
Expected Outcomes:
- [List expected patient improvements] (Include symptom relief, stabilization of vital signs, improved comfort, or enhanced functional status.)
- [Describe measurable indicators] (State how the patient’s progress will be assessed, such as reduced symptom severity, increased activity tolerance, or patient-reported improvement.)
Evaluation:
- [Describe observed patient response to interventions] (Indicate whether expected outcomes were met, partially met, or unmet.)
- [List remaining challenges] (Identify ongoing symptoms, functional limitations, or areas requiring continued intervention.)
3. INTERVENTIONS:
[list nursing interventions to address the nursing diagnosis and achieve the expected outcomes]
(Provide detailed, structured interventions in bullet points. Include assessment actions, direct care measures, patient education, and collaborative efforts.)
Assessment Interventions:
- [Describe ongoing monitoring activities] (Include frequency and method of tracking patient condition, such as checking vital signs, assessing respiratory function, or monitoring mobility levels.)
- [Describe indicators of progress or deterioration] (List signs that suggest improvement or worsening of the patient’s condition.)
Direct Care Interventions:
- [List nursing actions that directly address the patient’s condition] (Include strategies such as positioning, mobility support, airway management, pain control, or wound care.)
- [Describe any emergency measures if necessary] (Include steps for managing acute deterioration.)
Patient Education:
- [List key teaching topics] (Include information on symptom management, lifestyle modifications, medication adherence, and self-care instructions.)
- [Describe effective communication strategies] (Ensure instructions are tailored to the patient’s literacy level, language, and cultural background.)
Collaborative Interventions:
- [List interdisciplinary care strategies] (Include consultations or referrals to physicians, physical therapists, dietitians, social workers, or other healthcare professionals.)
- [Describe prescribed treatments, therapies, or medications] (Include dosage, administration guidelines, and necessary monitoring.)
(Use as many lines, paragraphs, or bullet points as needed to comprehensively document the nursing care plan. Never come up with your own patient details, assessment, plan, interventions, or evaluation—use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, do not state that the information has not been explicitly mentioned in your output—just leave the relevant placeholder blank or omit it completely.)
Sample Clinical Note

Example of completed documentation using this template

1. NURSING DIAGNOSIS:
Acute Pain related to surgical incision as evidenced by patient-reported pain level of 8/10 and guarding behavior.
Supporting Data:
- Objective data: Vital signs indicate an elevated heart rate of 110 bpm and blood pressure of 150/90 mmHg. Physical examination shows tenderness and swelling around the incision site.
- Subjective data: Patient describes sharp, throbbing pain at the incision site, rated 8/10 on the pain scale, and mentions, "It hurts more when I move."
2. OUTCOMES & EVALUATION:
The patient will report a pain level of 3/10 or less within 48 hours post-intervention.
Expected Outcomes:
- Pain relief to a manageable level, facilitating increased mobility and comfort.
- Measurable indicators: Patient reports a reduction in pain level to 3/10 or less, with improved ability to perform activities of daily living.
Evaluation:
- Observed patient response: Pain level decreased to 4/10 following administration of analgesics and repositioning.
- Remaining challenges: Patient continues to experience discomfort during movement, necessitating ongoing pain management.
3. INTERVENTIONS:
Assessment Interventions:
- Monitor vital signs every 4 hours to evaluate changes in pain-related physiological responses.
- Observe for signs of pain relief or exacerbation, such as alterations in facial expression or movement.
Direct Care Interventions:
- Administer prescribed analgesics according to physician's orders, ensuring timely pain relief.
- Assist with repositioning every 2 hours to reduce pressure and enhance comfort.
Patient Education:
- Educate the patient on the importance of accurately reporting pain levels for effective management.
- Use simple language and visual aids to explain pain management techniques.
Collaborative Interventions:
- Consult with the pain management team for potential adjustments to the analgesic regimen.
- Coordinate with physical therapy to develop a mobility plan that minimizes pain while promoting recovery.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template for nursing diagnosis is designed to enhance patient care by providing a structured approach to identifying and addressing patient needs. Utilizing standardized NANDA-I nursing diagnoses, this template ensures clarity and specificity in documenting the underlying causes, contributing factors, and defining characteristics of each diagnosis. Clinicians can rely on this template to systematically list objective and subjective data, such as vital signs and patient-reported symptoms, to support the diagnosis. The outcomes and evaluation section employs SMART criteria to define expected patient improvements and measurable indicators, facilitating precise tracking of patient progress. Detailed nursing interventions, including assessment, direct care, patient education, and collaborative efforts, are outlined to effectively address the diagnosis and achieve desired outcomes. This template encourages healthcare professionals to adopt a holistic and evidence-based approach, ultimately improving patient outcomes and streamlining clinical workflows.
Frequently Asked Questions

Common questions about this template and its usage

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