Nursing Handover Template
A free nursing handover template using the SBAR framework. Endorsed by NHS England and the WHO. No signup required.
What is a nursing care plan?
A nursing care plan is a patient-specific document that records a nurse's assessment, nursing diagnoses, goals, planned interventions, and evaluation of outcomes. It follows the ADPIE framework and is created for each patient at admission and updated throughout their stay.
The template
Nursing Care Plan Template
NURSING CARE PLAN
Patient identifier:
[Hospital number]
Date of plan:
[Date]
Admitting diagnosis:
[Diagnosis]
Nurse:
[Name and role]
Ward:
[Ward name]
Review date:
[Date]
STEP 1 - ASSESSMENT | What is the current patient status?
Subjective data (what the patient reports):
[Document what the patient says about their condition, symptoms, pain, concerns, and history in their own words where possible]
Objective data (what you observe and measure):
Vital signs:
Temperature:°C
Blood pressure:/
Heart rate:bpm
Respiratory rate:breaths/min
Oxygen saturation:%
Pain score:/ 10
Blood glucose:
Physical assessment findings:
[Document your head-to-toe assessment findings - appearance, level of consciousness, respiratory effort, skin integrity, mobility, nutrition, elimination, and any other relevant system findings]
Relevant medical history:
[List conditions relevant to this admission]
Current medications:
[List or reference medication chart]
Recent investigations:
[List relevant lab results, imaging, or test findings]
Psychosocial and cultural considerations:
[Note any relevant factors - language needs, family support, cultural or religious considerations, mental health, living situation]
STEP 2 - NURSING DIAGNOSIS | What are the identified nursing problems?
Nursing Diagnosis 1:
[State using NANDA-I format where possible: Problem + Related to + As evidenced by]
Example format:
[Problem] related to [contributing factor] as evidenced by [signs and symptoms]
Priority:
HighMediumLow
Nursing Diagnosis 2:
[State using NANDA-I format where possible]
Priority:
HighMediumLow
Nursing Diagnosis 3:
[State using NANDA-I format where possible]
Priority:
HighMediumLow
STEP 3 - PLANNING | What are the goals for this patient?
Goal for Nursing Diagnosis 1:
Short-term goal:
[State a measurable outcome expected within hours to days]
[Goals must be: Specific, Measurable, Achievable, Realistic, Time-bound]
Long-term goal:
[State a measurable outcome expected by discharge or over a longer period]
Goal for Nursing Diagnosis 2:
Short-term goal:
[State a measurable outcome]
Long-term goal:
[State a measurable outcome]
Goal for Nursing Diagnosis 3:
Short-term goal:
[State a measurable outcome]
Long-term goal:
[State a measurable outcome]
STEP 4 - IMPLEMENTATION | What nursing interventions are planned?
Interventions for Nursing Diagnosis 1:
Assessment interventions:
[What will you monitor and how often?]
Direct care interventions:
[What hands-on nursing care will you provide?]
Patient education interventions:
[What will you teach the patient or their carer?]
Collaborative interventions:
[What referrals or multi-disciplinary input is required?]
Rationale:
[Briefly state why these interventions address the nursing diagnosis]
Interventions for Nursing Diagnosis 2:
Assessment interventions:
[What will you monitor and how often?]
Direct care interventions:
[What hands-on nursing care will you provide?]
Patient education interventions:
[What will you teach the patient or their carer?]
Collaborative interventions:
[What referrals or multi-disciplinary input is required?]
Rationale:
[Briefly state why these interventions address the nursing diagnosis]
Interventions for Nursing Diagnosis 3:
Assessment interventions:
[What will you monitor and how often?]
Direct care interventions:
[What hands-on nursing care will you provide?]
Patient education interventions:
[What will you teach the patient or their carer?]
Collaborative interventions:
[What referrals or multi-disciplinary input is required?]
Rationale:
[Briefly state why these interventions address the nursing diagnosis]
STEP 5 - EVALUATION | Were the goals met?
Evaluation of Nursing Diagnosis 1:
Date of evaluation:
[Date]
Goal status:
- Goal met - describe findings:
- Goal partially met - describe:
- Goal not met - describe:
Plan going forward:
- Continue current plan
- Modify plan - describe changes:
- Discontinue - reason:
Evaluation of Nursing Diagnosis 2:
Date of evaluation:
[Date]
Goal status:
- Goal met - describe findings:
- Goal partially met - describe:
- Goal not met - describe:
Plan going forward:
- Continue current plan
- Modify plan - describe changes:
- Discontinue - reason:
Evaluation of Nursing Diagnosis 3:
Date of evaluation:
[Date]
Goal status:
- Goal met - describe findings:
- Goal partially met - describe:
- Goal not met - describe:
Plan going forward:
- Continue current plan
- Modify plan - describe changes:
- Discontinue - reason:
DISCHARGE PLANNING NOTES
Expected discharge date:
[Date]
Discharge destination:
[Home / Facility / Transfer]
Support required at home:
[Describe]
Referrals made:
[List]
Patient education completed:
YesPartial
Follow-up appointments:
[List]
SIGN-OFF
Completed by:
Name:Role:Date:
Reviewed by:
Name:Role:Date:
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What this template covers
Patient header
identifier, date, admitting diagnosis, nurse, ward, review date
Step 1 Assessment
subjective data, objective data including vital signs, physical assessment, medical history, medications, investigations, psychosocial factors
Step 2 Nursing Diagnosis
up to three diagnoses in NANDA-I format with priority rating
Step 3 Planning
short-term and long-term measurable goals per diagnosis
Step 4 Implementation
assessment, direct care, patient education, and collaborative interventions with rationale per diagnosis
Step 5 Evaluation
goal status, findings, and plan going forward per diagnosis
Discharge planning
expected date, destination, support, referrals, follow-up
Sign-off
completed and reviewed
How to use this template
Copy and complete the patient header
Fill in the patient identifier, admitting diagnosis, your name, and the date before starting the assessment.
Complete Step 1 - Assessment thoroughly
Gather both subjective and objective data before writing anything else. The quality of the care plan depends on the quality of the assessment.
Write nursing diagnoses in NANDA-I format
State each diagnosis as: Problem related to contributing factor as evidenced by signs and symptoms. Prioritise - high-priority diagnoses are addressed first.
Set measurable goals in Step 3
Every goal must be measurable and time-bound. Avoid vague goals like "patient will feel better." Write "patient will report pain score of 3 or below within 4 hours of intervention."
Complete interventions and rationale in Step 4
For each nursing diagnosis, document what you will monitor, what care you will provide, what you will teach, and what referrals are needed.
Evaluate and update at each review
Complete Step 5 at each scheduled review. If a goal is not met, modify the plan - do not leave an unmet goal without a revised approach.
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