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Download treatment plan template in Microsoft Word format.
Sample Treatment Plan: The Role Nurses Play
Are you a nursing student or someone working in the nursing field that could benefit from a sample treatment plan? Treatment plans are used by a wide range of health care providers, including doctors, dentists, psychiatrists and therapists, and while many people think of nurses as merely assistants to their attendant physician, the treatment these professionals provide is crucial in both the hospital and clinic setting. To illustrate this, first we will give a brief definition of a nursing treatment plan, followed by a sample treatment plan that outlines the specific categories and topics that are usually included.
What is a Nursing Treatment Plan?
When most people visit a doctor’s office, clinic or hospital, the first health care provider they will usually make contact with is a nurse—a trained professional who is educated and skilled to provide preliminary patient services as well as services that will assist physicians during treatment. We use the term “health care provider” here because that’s exactly the role that nurses play both before and during any treatment or diagnosis is provided by the doctor.
A nursing treatment plan can best be described as the formal document on which the nurse records important personal and medical information about a patient, along with any preliminary treatment steps that were provided. These documents are essential for proper treatment by the physician and for prioritizing patient care in a busy medical environment.
A prime example of this is the emergency room nurse, and chances are, if you’ve ever had to visit the emergency room you already know what a key role nurses play in terms of patient services. When a patient visits the emergency room, they will typically meet first with a nurse who will record information pertaining to the patient’s symptoms (type, onset and severity), as well as the patient’s medical history. Nurses will then measure a patient’s vital signs, including temperature, blood pressure, pulse and breathing, and provide any necessary treatment such as administering shots, drawing blood, cleaning and dressing wounds and issuing medication. All of these steps are recorded on the treatment plan in preparation for the attending physician, who will then prioritize the various patients in terms of the severity of their injury or illness as recorded on the nurse’s treatment plan. This type of care is absolutely crucial in this type of environment, especially when there are many patients waiting to see the physician at once.
Sample Treatment Plan: What Information Is Recorded on the Form?
Below are just a few of the categories/topics that would normally be recorded on a sample treatment plan for nurses:
- Patient name and contact information
- Insurance information
- Patient’s medical history
- List of medications that the patient is currently taking, and any allergies to medication or other substances
- Family medical history
- Symptoms, including type, onset, severity, etc.
- Vital signs, including blood pressure, body temperature, pulse and respiration
- Treatment provided—this could range from putting on a bandage to cleaning a gunshot wound
- Nurse’s diagnosis—based on the patient’s symptoms and medical history, nurses will often offer a preliminary diagnosis
- Priority—again, based on the severity of symptoms each patient displays, nurses in busy environments will help doctor’s prioritize patient care so the doctor is able to concentrate on the most serious cases first.
This sample treatment plan illustrates the vital services provided by nurses in a wide range of medical settings. This form of treatment is invaluable to busy physicians who often need to see multiple patients at any given time during the day.