A nursing care plan can present in two forms: informal and formal. Informal is a care plan for the individual use of the nurse and goals they wish to accomplish during their shift. Informal care plans are not included in the patient chart. A formal nursing care plan is a written or computerized guide that organizes patient care. It is further subdivided into two: standardized and individualized care plans. Standardized care plans are pre-populated care plans for specific patient populations, such as post-operative patients. Individualized care plans are tailored to the specific needs of the patient and adjust as the patient care journey evolves.
When developing and writing a nursing care plan, the nurse typically follows a five-step process: