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Nursing diagnosis template

Nursing diagnosis template

Create detailed, structured nursing assessments with this customizable template that helps organize diagnoses, interventions, and outcomes clearly.

Use this template
or download pdf
Nursing diagnosis template

Create detailed, structured nursing assessments with this customizable template that helps organize diagnoses, interventions, and outcomes clearly.

Use this template
or download pdf

About the Nursing diagnosis template

This nursing diagnosis template provides a structured framework that simplifies creating, sharing, and reviewing patient information. It helps you maintain consistency and focus on delivering quality care efficiently. By standardizing nursing assessments, you save time while covering critical details. This tool is perfect for healthcare teams looking to enhance collaboration, improve record accuracy, and support smoother handovers.

A step-by-step guide to using the nursing diagnosis template

Here’s how to make the most of the template:

  1. Customize the template to your needs. Before you begin, tailor the template to fit your specific healthcare setting or team’s workflow. You can add or adjust fields for unique defining characteristics, interventions, or expected outcomes. A personalized format ensures relevance and ease of use for your team.
  2. Enter patient information accurately. Start by filling out the patient’s basic details, including name, ID, and admission date. This initial step creates a clear record and helps to identify patients quickly during reviews or team handovers.
  3. Focus on precise nursing diagnoses. Use the provided fields to document the nursing diagnosis based on observed symptoms and medical data. Ensure this is aligned with the patient’s current condition for an actionable and effective care plan.
  4. Detail interventions and outcomes. Clearly outline the nursing interventions and expected outcomes. This step provides actionable guidance for frontline staff and sets measurable goals for patient care. A well-defined plan minimizes confusion and enhances care quality.
  5. Review and share with your team. Once completed, review the template to ensure all critical information is included. Share it with your team for seamless collaboration, then regularly update the document as the patient’s condition evolves.

How to customize the nursing diagnosis template

By customizing the template to fit your healthcare team’s needs, you can ensure it remains effective and relevant.

One option is to include dropdown options for frequently used diagnoses. For example, a pediatric unit might include options like “impaired nutrition,” “risk for infection,” or “delayed growth.” This reduces manual input errors and ensures diagnoses are categorized uniformly across records.

You can also customize interventions based on common treatments in your facility. If you specialize in post-surgical care, include pre-filled fields for common interventions like wound care, pain management, and mobility exercises. This makes the template more intuitive for your team, ensuring that you record critical actions quickly and accurately. .

Feel free to include quick-access links to guidelines or resources as well. You can embed links to clinical guidelines, treatment protocols, or patient education materials directly into the template.

Download Lumiform’s nursing diagnosis template today

Looking for a way to improve your workflow and keep patient records organized? This template is designed for professionals like you, providing a clear, customizable structure for capturing important patient data. It comes ready to fit into your routine with features like pre-built fields for diagnoses, interventions, and outcomes that you can tweak to match your facility’s needs.

Related categories

  • Health and safety management templates
  • Health care templates
  • Safety templates
Preview of the template
Page 1
Patient Information
Patient Name
Patient ID
Date of Admission
Nursing Diagnosis
Nursing Diagnosis
Related Factors
Defining Characteristics
Nursing Interventions
Nursing Interventions
Expected Outcomes
Evaluation Criteria
Additional Information
Relevant Patient History
Comorbidities
Medications

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Related resources

Access a complete set of resources aimed at maximizing safety, quality, and operational excellence, including detailed guides, related templates, and real-world use cases.

Topic guides

Read in-depth guides covering key topics related to this article.

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Frequently asked questions

What are the most common mistakes when documenting a nursing diagnosis?

One common mistake is being too vague or generic in the diagnosis, which can lead to unclear care plans. For example, writing “pain” without specifying its location, severity, or cause can leave the team guessing. Another error is skipping the related factors or defining characteristics.

How do I identify the related factors in a nursing diagnosis?

Related factors are the conditions or situations that contribute to the nursing diagnosis. Start by reviewing the patient’s history, clinical observations, and any current conditions. For example, if the diagnosis is “impaired mobility,” related factors could include joint pain, muscle weakness, or recent surgery.

What are some examples of actionable nursing interventions?

Actionable nursing interventions are specific steps that address the diagnosis directly. If the diagnosis is “risk for infection,” interventions might include regular wound dressing changes and patient education on hygiene practices. For “acute pain,” interventions could involve administering prescribed medications, repositioning the patient for comfort, or guiding relaxation techniques.


This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.
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