Chapter 49 documentation and nursing care plan form 2025

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They include; nursing plan, treatment plan, discharge plan and action plan.
Nursing care plans follow a five-step process: assessment, diagnosis, outcomes, implementation, and evaluation. Assess the patient. The first step to writing a care plan is performing a patient assessment. Make a diagnosis. Set goals and outcomes. Determine nursing interventions. Evaluate the plan.
The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.
Care plan documentation is not a legal document. Rather, it is a template used in nursing to properly and efficiently outline and plan the phases of a patients care journey. These documents are one of the main components involved in the health and wellness of a patient and are serve as a blueprint.
Documenting subjective data Nurses should also minimize falling back to phrases such as seems, appears, and feels as they are generally termed, Burrus says. Using subjective language, such as the patient seemed anxious, can introduce bias and lead to misinterpretations.
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There are several different types of nursing care plans, including informal, formal, standardized, and individualized. Individualized plans are those that can be tailored to the specific needs of a patient, particularly those sent to critical care.
Nursing care plans are structured as a five-step framework: assessment, diagnosis, outcomes and planning, implementation and evaluation.
Nursing care plans come in several different forms. These include informal plans, formal written plans, standardized plans, and individualized plans.

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