Explain the disease (What are the symptoms? What causes it?)
History . Explain what health problems the patient has (Has she/he been
diagnosed with other diseases?)
Detail any and all previous treatments (Has she/he had any prior.
surgeries or is he/she on medication?)
Nursing Physical . List all the patient’s health stats in sentences with specific
Assessment numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
Related Treatments . Explain what treatments the patient is receiving because of his/her
disease
Nursing Diagnosis & Patient . Explain what your nursing diagnosis is (What is the main problem
Goal for this patient? What need to be addressed?)
Explain what your goal is for helping the patient recover (What do
you want to change for the patient?)
Nursing Interventions . Explain how you will accomplish your nursing goals, and support
this with citations (Reference the literature)
Evaluation . Explain how effective the nursing intervention was (What happened
after your nursing intervention? Did the patient get better?)
Recommendations . Explain what the patient or nurse should do in the future to
continue recovery/improvement
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