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  • Person submitting the request.

  • Person submitting the request

  • Person submitting the request

  • Registered Nurse

  • Student Nurse

  • Allied Health Professionals

1. Patient Assessment Data

(Without Identifiers) 

  • Clinical Profile: 

    • Age group: [Pediatric/Adult/Geriatric]

    • Medical diagnosis (ICD-10 code): [______]

    • Functional status: [Ambulatory/Assisted/Bedbound]

  • Key Metrics: 

    • Vital signs trends

    • Pain score (0-10 scale)

    • Braden Scale (pressure injury risk)

    • Fall risk score (Morse Scale)

2. Nursing Diagnoses

(Using NANDA-I Taxonomy) 

  • Prioritized list:

    1. "Impaired Skin Integrity related to immobility..."

    2. "Risk for Infection secondary to surgical incision..."

One-Off Care Plans
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