Nursing Care Plan Design

Proof required

Submit your anonymised patient assessment record (structured by the chosen framework's domains), countersigned by your registered nurse supervisor who confirms you conducted the assessment under their direct supervision. Patient identifiers must be fully removed.

What gets checked

• Assessment framework is named and consistently applied — the assessment is structured by the model's domains, not as free prose.
• Clinical language is used throughout — 'the patient said they feel sad' is not clinical assessment language for a nursing record.
• Supervisor countersignature confirms direct observation of the assessment.

Common mistakes

• Assessment conducted without the supervisor present — the countersignature must confirm direct supervision, not just review of the completed record.
• Free-prose assessment that is not structured by the chosen framework — frameworks structure assessment to prevent omissions.
• Patient identifiers not fully removed — dates of birth, ward names, and diagnoses together constitute identifiable data.

Resources

What a verifier looks for

• Confirm the supervisor countersignature states direct observation — not review after the fact.
• Ask the student which assessment framework they used and why it is appropriate for this patient.
• Check that patient anonymisation is complete across the full document.

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Proof required

Submit your anonymised nursing care plan with at least 3 nursing diagnoses, each with SMART goals, interventions with rationale, and evaluation criteria. Countersigned by your registered nurse supervisor.

What gets checked

• Nursing diagnoses use the NANDA or approved taxonomy format — 'the patient has pain' is not a nursing diagnosis; 'Acute pain related to surgical incision as evidenced by patient-reported pain score 7/10 and guarding behaviour' is.
• Goals are SMART — time-bound, measurable, and achievable for this specific patient.
• Interventions include rationale — not just what to do but why each intervention addresses the nursing diagnosis.

Common mistakes

• Nursing diagnoses that conflate medical diagnoses with nursing diagnoses — care plans address nursing problems, not medical conditions.
• Goals that are not SMART — 'the patient will feel better' is not measurable or time-bound.
• Interventions without rationale — listing tasks without clinical justification is not a nursing care plan.

Resources

What a verifier looks for

• Ask the student to explain why they chose each nursing diagnosis over other possible diagnoses — tests prioritisation.
• Check that all three goals are SMART — ask 'how would you know at the end of the shift if this goal was met?'
• Ask for the rationale behind one specific intervention — tests understanding, not just task-listing.

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Proof required

Submit your care plan evaluation (2 pages) with specific clinical evidence for each goal assessment, and your supervisor's countersignature confirming they observed the implementation period. All patient identifiers must be anonymised.

What gets checked

• Each goal assessment includes specific clinical evidence — 'the patient improved' is not evidence; 'pain score reduced from 7/10 to 3/10 by day 3 and patient was mobilising independently on day 5' is.
• Unmet goals include an explanation — was the goal unrealistic, was an obstacle encountered, or was the intervention insufficient?
• Revised nursing diagnoses or interventions are proposed — the evaluation must close the care plan loop.

Common mistakes

• Evaluation written without the clinical implementation actually having occurred — supervisor countersignature must confirm the implementation period.
• Goals assessed as 'met' or 'not met' without clinical evidence for each assessment.
• Evaluation that does not propose any revisions — a care plan that led to perfect outcomes in all three nursing diagnoses requires explanation.

Resources

What a verifier looks for

• Ask the student to describe one specific clinical observation from the implementation period that informed their evaluation.
• Check that the supervisor's countersignature covers the implementation period, not just the written evaluation.
• Ask what the student would change in the care plan if they were to start again — tests whether the evaluation led to genuine learning.

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