A care plan directs the patient’s nursing care from admission to discharge. This written action plan is based on nursing diagnoses that have been formulated after reviewing assessment findings, and it embodies the components of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. (See Elements of a nursing diagnosis.) The care plan consists of three parts: goals or expected outcomes, which describe behaviors or results to be achieved within a specified time; appropriate nursing actions or interventions needed to achieve these goals; and evaluations of the established goals.

A nursing care plan should be written for each patient, preferably within 24 hours of admission. It’s usually started by the patient’s primary nurse or the nurse who admits the patient. If the care plan contains more than one nursing diagnosis, the nurse must assign priority to each diagnosis and implement those with the highest priority first. Nurses update and revise the plan throughout the patient’s stay, and the document becomes part of the permanent patient record.

Some health care facilities use standardized care plans that can be modified to serve many patients. Others use computer programs to facilitate development of nursing care plans. Most have preprinted care plan forms that can be filled in as needed, often on the nursing Kardex.