Nursing help

Care Plan Template

Patient Initials: ______ Age: _______________ Sex: ___________

Subjective Data:

Client Complaints:

HPI (History of Present Illness):

PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations):

Significant Family History:

Social/Personal History (occupation, lifestyle—diet, exercise, substance use)

Description of Client’s Support System:

Behavioral or Nonverbal Messages:

Client Awareness of Abilities, Disease Process, Health Care Needs:

Objective Data:

Vital Signs including BMI:

Physical Assessment Findings:

Lab Tests and Results:

Client’s Support System:

Client’s Locus of Control and Readiness to Learn:

ICD-9 Diagnoses/Client Problems:

Advanced Practice Nursing Intervention Plan ( including interdisciplinary collaboration, community resources and follow-up plans ):

References