Problem
A. Identify the Subjective Data. Identify what client says about concern being addressed.
B. Identify the Objective Data. Identify observable records from physical examination pertaining to the concern being addressed.
C. Assessment. Make brief summary of issue of concern that was identified by the nurse. Discusses client's existing conditions.
D. Plan. Make a detailed explanation of the healthcare plan to address the issue of concern . Holistic approach to care identified (ensure recommendations aren't only focused on pharmacological interventions).
E. Intervention. Make a brief description surrounding the intervention provided and how it was tolerated by the client.
F. Evaluation. Determine if the intervention was successful and identify the indicators that support this.