Section and Information to Include
Introduction (patient and problem)
Explain who the patient is (Age, gender, etc.)
Explain what the problem is (What were they diagnosed with, or what happened?)
Introduce your main argument (What should you as a nurse focus on or do?)
Pathophysiology
Explain the disease (What are the symptoms? What causes it?)
History
Explain what health problems the patient has (Have they been diagnosed with other diseases?)
Detail any and all previous treatments (Have they had any prior surgeries or are they on medication?)
Nursing Physical Assessment
List all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
Related Treatments
Explain what treatments the patient is receiving because of their disease
Nursing Diagnosis & Patient Goal
Explain what your nursing diagnosis is (What is the main problem 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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