Plan of Care Guidelines
Requirement: A typed Plan of Care (POC) will be handed in to your clinical instructor once
during the semester. Your POC must be evidence based as demonstrated by use of references
throughout the document- particularly in the “Rationale for Intervention” column. You must
include a reference page at the end of the document.
Medical Diagnosis (10 points)
Document pathophysiology, medical treatment, nursing management. Please use a separate page
for this section.
Labs (5 points)
Tests or procedures and analysis of lab values pertinent to admitting diagnosis, include and
explain abnormal results:
Assessment (25 points)
Document your head to toe assessment and include any subjective data that you obtained. The
assessment should be organized and focus on the patient’s priority problem, such as why they are
admitted to the hospital, etc. This may not be the problem today.
Medical/Interdisciplinary Plan of Care (5 points)
Document the medical diagnoses and plan of care identified by the health care provider and other
disciplines.
Nursing Plan of Care (30 points)
Assessment findings: 5 points
These assessment findings should support your choice of patient problem. What did you
find in your assessment of the patient that supports your nursing diagnosis?
Nursing Diagnosis (Problem label and etiology): 5 points
Should be clear and concise. You can use NANDA if it fits or describe the problem. i.e. acute
pain: abdomen r/t post op appendectomy (date) or if the etiology is not known
Patient Safety issues: 5 points
Identify any possible safety issues or complications that may occur as a consequence of the
problem and etiology identified. i.e. acute pain: abdomen r/t unknown possibly a bowel
obstruction or a perforated bowel or maybe they cannot take a deep breath and atelectasis is a
possibility.
Desired Outcomes: 5 points
What was your goal for the patient? Should be measureable and be directly related to the
problem, etiology, S&S, and patient safety issues. i.e. pain reported 0-3/10; abdomen soft, no
N/V, BP and P stable, temp and SAO2 >94% on room air
Interventions: 5 points
What did you do? Should be specific and address each desired outcome. Imagine drawing a line
from each desired outcome to an intervention. Note that one intervention may help the patient
achieve multiple desired outcomes. Include the rationale with a reference for each intervention
(or group of interventions)
Evaluation: 5 points
Evaluate each goal. What was the actual outcome?
Medication (20 points)
Fill in all the columns using a valid and reliable resource (drug guide, text book, etc.). Be sure
that you have included your patient’s indication and specific nursing actions that you either
carried out or WOULD in the future.
Note (5 points)
Write a focused nursing note on the back of this page using the format of your facility reflecting
your patient’s priority problems and their responses to the Plan of Care
ALL SECTIONS OF THE CARE PLAN MUST BE COMPLETED TO ACHIEVE A PASSING
GRADE.
Reflective journals
What was the most significant experience you had this week? The experience can be an incident,
an encounter
focus, or a discovery about self, client, nursing profession, multidisciplinary team. Be sure to
FOCUS on how you felt and what you thought.
·
In addition to this, you may also want to think about:
o If you could go back and “do over the day” what might you do differently?
o How did you partner with the patient/family in planning care? Consider QSEN Patient
Centered Care, reflection
·
On days when you had the following assignments, please discuss how you felt, what was
going through your head, did you have any concerns at the beginning of the day, how did you
feel at the end of the day?
o Team Leader
o OR Experience
o Medication Administration
In your final journal entry you should reflect on a patient or experience you had this semester.
Discuss why it was significant and how/why it will/has impacted your nursing practice.