The Nurse’s Guide to Writing a Care Plan | USAHS (2023)

Care plans are a way to strategically approach and streamline the nursing process. They also enable effective communication in a nursing team. This guide will help you understand the fundamentals of nursing care plans and how to create them, step by step. We’ll also outline best practices to keep in mind and provide you with a nursing care plan sample that you can download and print.

Table of Contents

• What Is a Nursing Care Plan?
• What Are the Components of a Care Plan?
• Care Plan Fundamentals
• Sample Nursing Care Plan

What Is a Nursing Care Plan?

A nursing care plan documents the process of identifying a patient’s needs and facilitating holistic care, typically according to a five-step framework. A care plan ensures collaboration among nurses, patients, and other healthcare providers. ((M. Vera., “Nursing Care Plans (NCP): Ultimate Guide and Database”, July 5, 2021: https://nurseslabs.com/nursing-care-plans/)) ((Medical Dictionary for the Health Professions and Nursing, Farlex, “nursing care plan”, 2012: https://medical-dictionary.thefreedictionary.com/nursing+care+plan)) ((Health Navigator, “Care planning”, April 6, 2021: https://www.healthnavigator.org.nz/clinicians/c/care-planning/)) ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/))

Key Reasons to Have a Care Plan

The purpose of a nursing care plan is to document the patient’s needs and wants, as well as the nursing interventions (or implementations) planned to meet these needs. As part of the patient’s health record, the care plan is used to establish continuity of care. ((C. Björvell et al., “Development of an audit instrument for nursing care plans in the patient record,” Quality in Health Care, March 1, 2000: https://qualitysafety.bmj.com/content/qhc/9/1/6.full.pdf)) These are the main reasons to write a care plan:

• Patient-centered care

A care plan helps nurses and other care team members organize aspects of patient care according to a timeline. It’s also a tool for them to think critically and holistically in a way that supports the patient’s physical, psychological, social, and spiritual care. Sometimes a patient should be assigned to a nurse with specific skills and experience; a care plan makes that process easier. For patients, having clear goals to achieve will make them more involved in their treatment and recovery. ((Health Navigator, “Care planning”, April 6, 2021: https://www.healthnavigator.org.nz/clinicians/c/care-planning/))

• Nursing team collaboration

Writing a care plan allows a team of nurses (as well as physicians, assistants, and other care providers) to access the same information, share opinions, and collaborate to provide the best possible care for the patient.

• Documentation and compliance

A well-written care plan allows nurses to measure the effectiveness of care and to record evidence that the care was given. This is important both to maximize care efficiency and to provide documentation for healthcare providers.

What Are the Components of a Care Plan?

Care plans are structured as a five-step framework: assessment, diagnosis, outcomes and planning, implementation, and evaluation. ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/))

Step 1: Assessment

The first step of writing a care plan requires critical thinking skills and data collection. Different healthcare organizations use different formats for the assessment phase. In general, the data you will collect here is both subjective (e.g., verbal statements) and objective (e.g., height and weight, intake/output). The source of the subjective data could be the patients or their caretakers, family members, or friends.

Nurses can gather data about the patient’s vital signs, physical complaints, visible body conditions, medical history, and current neurological functioning. Digital health records may help in the assessment process by populating some of this information automatically from previous records.

Step 2: Diagnosis

Using the collected data, you will develop a nursing diagnosis—which the North American Nursing Diagnosis Association (NANDA) defines as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.” ((NANDA, “Glossary of Terms”: https://nanda.org/publications-resources/resources/glossary-of-terms/))

A nursing diagnosis sets the basis for choosing nursing actions to achieve specific outcomes. A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid ((Saul McLeod, “Maslow’s Hierarchy of Needs,” Simply Psychology, Dec. 29, 2020: https://www.simplypsychology.org/maslow.html)) (which identifies and ranks human needs) and helps prioritize treatments. For example, physiological needs (such as food, water, and sleep) are more fundamental to survival than love and belonging, self-esteem, and self-actualization, so they have the priority when it comes to nursing actions. ((Chiung-Yu Shih et al, “The association of sociodemographic factors and needs of haemodialysis patients according to Maslow’s hierarchy of needs,” Journal of Clinical Nursing, July 30, 2018: https://pubmed.ncbi.nlm.nih.gov/29777561/))

Based on the diagnosis, you’ll set goals (Step 3) to resolve the patient’s problems through nursing implementations (Step 4).

Step 3: Outcomes and Planning

After the diagnosis is the planning stage. Here, you will prepare SMART goals (more detail on this later) based on evidence-based practice (EBP) guidelines. You will consider the patient’s overall condition, along with their diagnosis and other relevant information, as you set goals for them to achieve desired and realistic health outcomes for the short and long term.

Step 4: Implementation

Once you’ve set goals for the patient, it’s time to implement the actions that will support the patient in achieving these goals. The implementation stage consists of performing the nursing interventions outlined in the care plan. As a nurse, you will either follow doctors’ orders for nursing interventions or develop them yourself using evidence-based practice guidelines.

Interventions are classified into the following seven domains: family, behavioral, physiological, complex physiological, community, safety, and health system interventions. There are several basic interventions that you need to implement during each shift: pain assessment, changing the resting position, listening, cluster care, preventing falls, and fluid consumption.

Step 5: Evaluation

In the final step of a care plan, the health professional (who can be either a doctor or a nurse) will evaluate whether the desired outcome has been met. You will then adjust the care plan based on this information.

Care Plan Fundamentals

In a simple but useful way, Nurse.org explains the core questions your care plan should answer: what, why, and how. ((Mariam Yazdi, “4 Steps to Writing a Nursing Care Plan,” Nurse.org, March 23, 2018: https://nurse.org/articles/nursing-care-plan-how-to/)) A nursing care plan should include:

• The What: What does the patient suffer from? What do they risk suffering from?
• The Why: Why does your patient suffer from this? Why do they risk suffering from this?
• The How: How can you make this better?

Successful care plans use the fundamental principles of critical thinking, client-centered techniques, goal-oriented strategies, evidence-based practice (EBP) recommendations, and nursing intuition. ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/))

SMART Goals

In the planning phase of writing a care plan, it’s important that you use goal-oriented strategies. A SMART goals template can help in this process:

• Specific: Your goals for the patient must be well-defined and unambiguous.
• Measurable: You need to set certain metrics to measure the patient’s progress toward these goals.
• Achievable: Their goal should be possible to achieve.
• Realistic: Their goals must be within reach and relevant to the overall care plan.
• Time-bound: The patient’s goals should have a clear starting time and end date (which can be flexible).

Effective Communication

Unless your care plan is communicated effectively to all relevant stakeholders, it will only be a plan. Remember that the purpose of a nursing care plan is not to be a static document, but to guide the entire nursing process and enable teamwork, with the goal of improving care. Writing skills are crucially important for nurses—you’ll need to be as accurate and current as possible in your descriptions. For effective communication, keep in mind the following best practices when writing a care plan:

• Write down everything immediately so you don’t forget the details.
• Write clearly and concisely, using terms that your team will understand.
• Include dates and times.

Although you will learn communication skills in an undergraduate or graduate nursing program, you will also develop them over time and with practical experience. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/))

Shareable and Easy to Access

Care plans also need to be easy to share with the relevant stakeholders—patients, doctors, other members of the nursing team, insurance companies, etc. The documentation format will vary according to hospital policy, but, in general, care plans are created in electronic format and integrated into the electronic health record (EHR) for easy access to everyone. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/))

Up to date

Finally, you will need to update your care plans often with the latest information. That implies checking in with patients frequently and recording data about how the patient is progressing toward their goals, which will be important in the evaluation stage of the care plan. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/))

Sample Nursing Care Plan

Despite the overall general objective, nursing care plans written by students are not the same as those created by registered nurses in clinical settings. The student version is much longer, has a greater level of detail, and is exhaustively thorough. On the other hand, nurses often assume some basic concepts and note some of the steps in the care plan only mentally. ((M. Vera., “Nursing Care Plans (NCP): Ultimate Guide and Database”, July 5, 2021: https://nurseslabs.com/nursing-care-plans/))

For example, in the interventions section, a student would write: “vital signs recorded every four hours: blood pressure, heart rate, three- or five-lead electrocardiograms, functional oxygen saturation, respiratory rate, and skin temperature,” while an experienced registered nurse might just write “Q4 vital signs.”

Why this difference? As a student or recent graduate, including all the information in your care plan will help you solidify your training. While writing care plans in school can be a very time-consuming task, mastering this information in nursing school will improve your competency and confidence. Most of the information that you’ll have to look up while you’re still in school will become second nature in the future. Here’s what a care plan written by a student looks like:

• Assessment: “heart rate 100 bpm, dyspnea, restlessness, guarding behavior.”
• Diagnosis: “impaired gas exchange RT collection of mucus in airway.”
• Outcomes and planning: “patient must maintain optimal gas exchange.”
• Implementations: “assess respiration; encourage breathing and position changes.”
• Rationale: “respiration will indicate the level of lung involvement, as the patient will adjust their breathing to facilitate gas exchange; these will improve ventilation and allow for chest expansion.”
• Evaluation: “the patient maintained good gas exchange, normal respiratory rate.”

Note that student care plans often have an additional column—rationale—where students note the scientific explanation for the implementations they chose. To help you get started with a care plan writing practice, we’ve created a printable nursing care plan, which you can use to practice writing all the steps outlined in this article.

Wrapping Up: Writing an Effective Nursing Care Plan

To be successful, a nursing plan needs effective communication, goal-oriented tasks, accessibility and shareability, and evidence-based practice.

When it meets these qualities and is supported by the nurse’s intuition, critical thinking, and a general focus on the patient, a nursing care plan becomes a go-to resource for nurses to record and access all the information they need. A care plan is your roadmap for effective nursing care, and a collaboration tool that improves the entire healthcare process.

While all nursing programs teach the basics of writing a care plan, your communication, goal setting, and critical thinking skills will be shaped by the program you attend.

For example, one of the benefits of writing care plans is that it will allow you to develop professionalism, along with important values like accountability, respect, and integrity. Key results of professionalism include better overall care, improved team communication, and a more positive work environment. ((Nursco, “Professionalism in Nursing – 5 Tips for Nurses,” July 13, 2018: https://www.nursco.com/professionalism-nursing-5-tips-nurses/))

That’s why it’s important that you choose the right program for your needs—one that will help you develop communication and critical thinking skills, as well as professionalism, to be ready for the day-to-day nursing life.

The University of St. Augustine for Health Sciences (USAHS) offers a Master of Science in Nursing degree (MSN), a Doctor of Nursing Practice degree (DNP), and Post-Graduate Nursing Certificates designed for working nurses. Our degrees are offered online, with optional on-campus immersions.* Role specialties include Family Nurse Practitioner (FNP), Nurse Educator ,** and Nurse Executive. The MSN has several options to accelerate your time to degree completion. Earn your advanced nursing degree while keeping your work and life in balance.

*The FNP role specialty includes two required hands-on clinical intensives as part of the curriculum.

**The Nurse Educator role specialty is not available for the DNP program.