What is the primary document used for nursing care planning?

The primary document used for nursing care planning is the 24 Hour Care Plan. This document serves as a comprehensive blueprint for the patient’s nursing care, detailing specific nursing diagnoses, individualized goals, and the interventions necessary to achieve those goals within a specified timeframe, typically over a 24-hour period. By outlining care priorities and responsibilities, this plan ensures that all members of the healthcare team are aligned with the patient’s needs and objectives.

While other documents, such as the Patient Care Report, Nursing Intervention Record, and Patient Progress Note, provide valuable insights and details regarding patient care, they do not serve the same primary function in terms of overall care planning. The 24 Hour Care Plan stands out as it is specifically designed to ensure continuity and coherence in nursing practice, facilitating effective communication among healthcare providers and supporting optimal patient outcomes.