Procedure:
Nursing Diagnosis and Medical Diagnosis: document this information in the area provided
Document the patient's INITIALS ONLY
Write up One priority nursing diagnosis.
Subjective data: document the information that the PATIENT TELLS you. Document only that information which supports the Nursing Diagnosis that you are addressing.
Objective data: document the information that YOU obtain from physical assessment. Document only that information which supports the Nursing Diagnosis that you are addressing.
Measureable Goal: Write ONE short term patient oriented measureable goal for the Nursing Diagnosis. Nursing Interventions: List at least 5 Nursing Interventions necessary to fulfill this goal.
Evaluation: Identify the following:
Whether or not the goal was met
If the goal was met, what data supports that the goal was met?
If the goal was NOT met, what adjustments need to be made to the plan of care and why?
Rationale Document:
List the Nursing Intervention by number.
Provide evidence for each Nursing Intervention.
Provide the full citation for each rationale.