Generic Worksheet/Nursing Care Plan
This is a working document designed to assist you in creating a Nursing Care Plan. For each client you “meet” this semester, you will:
● Review the Client Profile
● Review the Client Care Summary/Kardex
● Complete the Clinical Assessment Tool (CAT)
● Consider organization and time management with the Personal Organizational Plan (POP)
● Create a Nursing Care Plan.
Client Name:
Primary Medical Diagnosis:
Other Medical Diagnoses:
Living & Social History (eg. type of dwelling, significant other(s)/social supports - family/pets, employment history & financial
status, level of independence & autonomy, hobbies, cultural or spiritual considerations, home care services)
Things to Consider (eg. how am I going to introduce myself?, what kind of communication strategies will I use?, what is
significant about the client’s condition?, can I provide care by myself or do I need help?, how does my care connect with CNO
NSE121 – Generic Worksheet/Nursing Care Plan
2025
standards of practice?, how do I interact with the interprofessional team? RN, MD, UCP?)
Things to Research: (eg. what do the abbreviations mean?, what do I need to understand about client’s health condition?)
Nursing Process
Steps
Clinical Judgement
Model
Identify data found on Kardex/Client care summary relevant to the care.
Assessment
Recognizing and
Analyzing Cues
Identify further data needed before providing client care.
NSE121 – Generic Worksheet/Nursing Care Plan
2025
Nursing Process
Steps
Clinical Judgement
Model
Generate Nursing Diagnoses relevant to client (remember to consider physiological and psychosocial
needs).
Diagnosis
Prioritizing
Hypotheses
Planning
Generating Solutions Identify goals or desired outcomes for the client, related to the nursing diagnosis identified above. This
should describe the client response you expect to achieve as a result of interventions (Goals should be
SMART goals).
Describe with rationale the activities, including nursing interventions, required to provide care. List the
activities in the order that you will complete them.
NSE121 – Generic Worksheet/Nursing Care Plan
2025
Nursing Process
Steps
Clinical Judgement
Model
Implementation: Identify specific equipment items that you would need to prepare to take to the bedside to provide the
care you have planned above.
Taking Action
NSE121 – Generic Worksheet/Nursing Care Plan
2025
Nursing Process
Steps
Clinical Judgement
Model
Can you think of any other communication strategies to be used during implementation of care for this
client?
What safety factors do you need to consider while providing care for this client?
For the nurse: For the client:
Identify and give rationale for the infection control practices that you would use while implementing this
care.
NSE121 – Generic Worksheet/Nursing Care Plan
2025
Nursing Process
Steps
Clinical Judgement
Model
While providing this care, what other assessments will you make?
Evaluation For the goal/desired outcome identified above, describe how you will evaluate your intervention.
(Evaluation should reflect the goal / outcome related to the nursing diagnosis)
Evaluating
Outcomes
NSE121 – Generic Worksheet/Nursing Care Plan
2025
Nursing Process
Steps
Clinical Judgement
Model
Documentation Write a progress note or consider significant data to be documented.
ISBAR Consider how to communicate significant information to the interdisciplinary team. (eg. shift change,
conference, physician, OT/PT etc.)
NSE121 – Generic Worksheet/Nursing Care Plan
2025
