S
I
T
U
A
T
I
O
N
B
A
C
K
G
R
O
U
N
D
Nurse Process Worksheet
Patient/Age/Bed#
S
Priority Nursing Dx
Chief Complaint
Smart Goal
Diagnosis
B
Past Medical history
Code
Allergies
Status
Isolation Organism
Type
Intervention/
Procedure/
Imaging Results
Interventions
Goal Met
A
Not Met
Priority Nursing Dx
Neuro
Respiratory
Cardiac
A
S
S
E
S
S
M
E
N
T
Name:
Smart Goal
GI/GU
BM/Foley
Musculoskeletal/
Activity Level
Skin
Psychosocial/
Smoker Risk
Interventions
Positive
Vitals/Pulse Ox/Pain
I&O
Diet
Abnormal Labs/
Accucheck
R
E
C
O
M
M
E
N
D
A
T
I
O
N
Goal Met
Not Met
Risk For Dx
Vascular Access
Device Type/
IV Soln/Rates
Smart Goal
R
Interventions
Plan of Care
Consults/Referral
Tests/Treatments/
Appointment
Discharge Planning
Goal Met
Not Met