ATI Care Plan Template: How to Fill It Out in EHR, Format, Examples, and Tips for Nursing Students

The ATI care plan template is a structured nursing care plan format used by Assessment Technologies Institute (ATI) — the same organization that produces TEAS exams and ATI test prep materials — in many nursing programs. ATI care plans are required in clinicals, simulation labs, and as graded assignments. Filling them out correctly takes practice and a clear understanding of the nursing process.

What's in an ATI care plan. The template includes patient assessment data (demographics, history, current state), nursing diagnoses with related factors and as-evidenced-by statements, expected outcomes (SMART goals), nursing interventions with rationales, evaluation of outcomes, and reflection. The template forces you to use the full nursing process: Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE).

Why ATI uses this format. The template aligns with NANDA-I nursing diagnoses and standardized nursing practice. It builds the habits clinical instructors and nursing licensure boards expect. Students who complete ATI care plans well develop the analytical thinking required for NCLEX and clinical nursing.

Where you'll fill it out. Many programs use ATI in their EHR (electronic health record) integration. Templates may be in ATI Nursing Education's online portal, in your school's PowerChart or other clinical documentation system, or as PDFs/Word documents you complete and submit. The structure is similar across formats.

This guide walks through each section of the ATI care plan template, provides examples for common diagnoses, and offers tips for high-grade assignments. It's for nursing students completing clinical care plans during their program.

Section 1: Patient assessment. The foundation of every good care plan.

Demographics. Patient initials (HIPAA compliance), age, gender, race, marital status, occupation. Don't include real names or identifiers.

Admission info. Date of admission, admitting diagnosis, chief complaint, length of stay, current room/unit, primary care provider.

Past medical history. Significant comorbidities (diabetes, hypertension, COPD, etc.). Past surgeries. Allergies (drug, food, environmental). Code status (full code, DNR, etc.). Mental health history. Substance use.

Current condition. Why are they here now? Pathophysiology of admitting diagnosis (in your own words, brief 1-2 paragraphs). Current symptoms. Recent changes.

Physical assessment data. Vital signs (with normal ranges noted). Head-to-toe assessment findings: neurological, cardiovascular, respiratory, GI, GU, musculoskeletal, integumentary. Recent lab values (with abnormal flagged). Diagnostic test results (imaging, EKG, etc.). Medications currently administered with classification, dose, route, frequency.

Psychosocial assessment. Cultural/religious considerations. Support system. Cognitive status. Emotional state. Communication preferences. Health literacy.

Family/social history. Living situation. Family members involved in care. Insurance status. Employment status. Education level.

What makes a good assessment. Specificity: 'Lung sounds: bilateral diminished bases with rhonchi RUL' beats 'lung sounds abnormal.' Linking findings to admitting diagnosis. Identifying patterns and clusters. Noting changes from baseline (compare to prior shifts).

Tips for ATI assessment section. Print out a head-to-toe checklist and use it consistently. Verify lab normal ranges against your school's references. Pull current medication info from EHR (don't memorize wrong doses). Note changes from prior shifts. Identify what's most clinically relevant.

Section 2: Nursing diagnoses. The heart of the care plan.

Use NANDA-I diagnoses. ATI requires exact NANDA-I language. Sources: NANDA International book (latest edition), Nursing Diagnoses: Definitions and Classifications by Heather Herdman, ATI's Nursing Care Plans Made Incredibly Easy.

The three-part diagnosis format. Problem statement: NANDA-I diagnosis label. Related to (etiology): underlying cause. As evidenced by (signs/symptoms): objective and subjective data. Example: 'Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by SpO2 88% on room air, RR 28, accessory muscle use, and patient report of dyspnea on exertion.'

Common ATI categories. Physiological: Impaired Gas Exchange, Acute Pain, Deficient Fluid Volume, Impaired Skin Integrity, Impaired Physical Mobility, Risk for Infection. Safety: Risk for Falls, Risk for Aspiration, Risk for Injury. Psychosocial: Anxiety, Disturbed Body Image, Caregiver Role Strain. Knowledge: Deficient Knowledge, Readiness for Enhanced Health Management. Family: Family Process, Interrupted Family Process.

Prioritization. Use Maslow's hierarchy: physiological needs (airway, breathing, circulation) first, then safety, then psychosocial, then self-actualization. ABCs (Airway, Breathing, Circulation, Disability) for acute care. ATI expects you to identify the most urgent diagnosis first.

Common errors. Wrong NANDA-I label. Missing 'related to' or 'as evidenced by' parts. Using nursing diagnoses that are actually medical diagnoses (e.g., 'Pneumonia' is medical, not nursing — nursing equivalent is 'Impaired Gas Exchange' or 'Ineffective Airway Clearance'). Diagnoses too general or too specific.

How many diagnoses. Typically 2-3 for a clinical patient. Prioritize. Don't list every possible problem — focus on what you can realistically address during your shift or assignment.

Risk vs Actual diagnoses. Actual diagnosis: problem currently present (Acute Pain). Risk diagnosis: problem could develop based on current condition (Risk for Falls). Both important; risk diagnoses prevent problems.

Section 3: Expected outcomes (goals). SMART goals tied to each diagnosis.

SMART criteria. Specific: What exactly will the patient do? Measurable: How will you know? Achievable: Is this realistic for this patient? Relevant: Tied to the diagnosis. Time-bound: When?

Example. Diagnosis: Acute Pain r/t surgical incision. Goal: 'Patient will report pain rating of 4 or less on a 0-10 scale within 30 minutes of receiving prescribed pain medication during this shift.' This is specific (4/10 pain), measurable (numeric rating), achievable (with appropriate pain management), relevant (addresses the diagnosis), and time-bound (within 30 minutes of medication).

Short-term vs long-term goals. Short-term: achievable during shift or hospitalization. Long-term: post-discharge or rehabilitation. ATI typically wants 1-2 short-term goals per diagnosis.

Patient-centered language. Always start with 'Patient will...' or 'Patient verbalizes...' Not 'Nurse will...' (interventions, not outcomes).

Realistic for the patient. Goals should match patient capacity. 'Patient will ambulate 50 feet' is great for some patients; '10 feet' is more realistic for others. Set goals you can actually expect to achieve.

Outcome examples by diagnosis. Acute Pain: Patient reports pain 4/10 or less. Anxiety: Patient demonstrates relaxation techniques. Knowledge deficit: Patient verbalizes 3 dietary modifications. Risk for falls: Patient calls for assistance before ambulating. Skin integrity: Wound shows signs of healing without infection.

How many outcomes per diagnosis. Typically 1-2. Don't list everything possible — focus on what's most relevant and achievable.

Tying to evidence. ATI loves citations. Cite Nursing-Care Plans, Pearson Nursing Interventions, or NANDA-I texts for evidence-based interventions and expected outcomes.

Section 4: Nursing interventions with rationales. The action plan.

Structure. For each diagnosis: 4-6 nursing interventions. Each with rationale (why this intervention).

Categories of interventions. Independent: nursing actions within scope (assess, monitor, educate, position, etc.). Dependent: require physician order (administer medications, restrain, etc.). Interdependent/collaborative: involve other disciplines (consult dietary, physical therapy referral, etc.).

Specific interventions for pain. Assess pain using 0-10 scale q4 hours and prn (Rationale: Frequent assessment ensures unrelieved pain isn't missed). Administer prescribed analgesics per orders (Rationale: Medications block pain pathways). Position for comfort using pillows for support (Rationale: Proper positioning reduces muscle tension and pressure). Use complementary techniques: deep breathing, music therapy (Rationale: Non-pharmacological methods supplement medication). Reassess pain 30 minutes post-medication (Rationale: Determines effectiveness of intervention). Encourage patient to report when pain begins, not when severe (Rationale: Early intervention is more effective).

Specific interventions for impaired gas exchange. Assess respiratory status q2 hours: rate, rhythm, depth, lung sounds, oxygen saturation. Administer oxygen per orders to maintain SpO2 above 92%. Position upright in semi-Fowler's to facilitate breathing. Encourage incentive spirometry every 1-2 hours while awake. Teach pursed-lip breathing technique. Monitor for signs of respiratory distress: tachypnea, accessory muscle use, cyanosis.

Each intervention with rationale. Pearson's Nursing Interventions Classification (NIC) is the standard reference. ATI usually accepts: nursing textbook references, evidence-based practice guidelines, peer-reviewed articles. Format: 'Intervention. Rationale (Citation, year).'

Avoiding common pitfalls. Generic interventions ('provide comfort care') — too vague. Always add specifics. Missing rationales — every intervention needs one. Dependent without order — make sure you cite the order.

Number of interventions. Aim for 4-6 per diagnosis. Quality over quantity. Each should address the goal.

Prioritization within interventions. Sometimes denote priority (e.g., Priority 1, 2, 3). Most urgent: assess and address vital signs first.

Section 5: Evaluation. Did the plan work?

What evaluation includes. Outcome status (met, partially met, not met). Evidence supporting the evaluation (objective data, patient self-report). Modification needed if not met.

Examples. Goal: Pain 4/10 or less within 30 minutes. Evaluation: 'Met. Patient reported pain 3/10 30 minutes after IV morphine 4 mg. Reports adequate relief.' Goal: Ambulate 30 feet without assistance. Evaluation: 'Partially met. Patient ambulated 20 feet with walker before requesting rest. Will continue PT consults.'

If outcome not met. Don't ignore. Document why (patient too weak, intervention ineffective, pain limited mobility). Revise plan: new outcomes, different interventions, or additional collaborative care.

Continuous evaluation. ATI care plans expect re-evaluation. As you continue providing care, outcomes update. New diagnoses may emerge. Plan is fluid, not static.

Patient response. Document subjective: how does patient feel? Document objective: what do you observe? Both inform evaluation.

Family/support. Sometimes goals involve family involvement. Document their participation and response.

Section 6: Reflection. Often required component.

Reflection prompts. What did you learn from this experience? What went well? What would you do differently? How did your initial nursing diagnosis change as you cared for the patient? What did you observe that surprised you? What evidence-based practice would you apply differently next time?

Quality reflection. Specific examples. Connect to course objectives or competencies. Show critical thinking. Demonstrate growth or learning.

Examples of good reflection. 'Initially I focused on the patient's pain, but I quickly realized her anxiety was the main barrier to recovery. After spending time listening to her fears about surgery, her cooperation with pain management improved.' 'I learned that even when patients refuse interventions, our role is to provide information and respect autonomy while documenting the discussion.'

Tips for high-scoring ATI care plans.

Plan ahead. Start the care plan as you collect data, not at the end of shift. Maintain a notebook with patient data throughout the day.

Be specific. Generic care plans get average grades. Specific, patient-tailored plans get high grades. 'Assess pain every shift' is vague; 'Assess pain using 0-10 scale every 2 hours and PRN, document location, character, severity' is specific.

Use evidence. Cite sources for interventions and rationales. Pearson, ATI textbooks, NIC manual, NANDA-I, peer-reviewed nursing journals all acceptable.

Prioritize correctly. Maslow first. ABCs of acute care. Don't list 'Anxiety' as Priority 1 when the patient has unstable vital signs.

Match diagnoses to interventions. Each intervention should clearly address the diagnosis. Don't include random interventions just to fill space.

Format consistently. Use the same format throughout (e.g., consistent use of bullets, numbered lists, citation style).

Proofread. Submit care plans without typos, formatting errors, or missing sections. Demonstrates professionalism.

Reference NANDA-I exactly. Look up exact diagnosis labels. 'Pain' is wrong; 'Acute Pain' or 'Chronic Pain' is correct.

Show your nursing thinking. Demonstrate that you understand why you're doing what you're doing. Strong reflection shows growth.

Use your school's specific template. Different schools modify templates slightly. Follow your school's exact format.

How to fill out in EHR systems.

Common EHR systems used in nursing programs. Epic (largest in U.S.). Cerner PowerChart. Allscripts. ATI's own integrated platform. Each has slightly different navigation but similar information collection.

General workflow in EHR. 1. Find patient: search by MRN or name. Access their chart. 2. Navigate to care plans section: usually under 'Plan of Care' or 'Nursing Documentation.' 3. Select 'New Care Plan' or 'ATI Care Plan' template. 4. Auto-populated fields from chart data (demographics, allergies, medications, recent labs). 5. Add nursing diagnoses: search NANDA-I or type in. 6. Add expected outcomes for each diagnosis. 7. Add interventions: pull from intervention library or write custom. 8. Document evaluation. 9. Sign and save.

EHR-specific tips. Epic: care plans often under 'Plan of Care' or 'Patient Education.' Click 'Care Plan' button. Cerner: 'PowerChart' has nursing care plan templates in clinical documentation. Allscripts: 'Nursing Care Plan' template in clinical workflow.

Auto-populated vs manual fields. Most EHRs pull from existing data. Verify accuracy before relying on auto-populated info. Manually entered fields: nursing diagnosis, outcomes, interventions, evaluation, reflection.

Multiple users. EHRs allow multiple users to edit. Some require check-out/check-in. Coordinate with team if multiple students using same patient.

Saving and printing. Save frequently — don't lose work due to timeout. Some EHRs auto-save. Print PDF for assignment submission if required.

Patient privacy. Use proper identifiers in EHR. HIPAA: never share screens with patient info. Log out when leaving station. Use secure printing only.

EHR-specific challenges. Slow systems: be patient. Lost connection: save frequently. Forgot password: contact IT, not your instructor. Wrong patient: verify before documenting.

Common care plan scenarios.

Post-operative patient. Common diagnoses: Acute Pain, Risk for Infection, Impaired Skin Integrity, Risk for Falls, Knowledge Deficit (post-op care). Outcomes: pain controlled, wound shows no signs of infection, ambulates safely. Interventions: pain management, dressing changes, ambulation, education.

Cardiac patient. Diagnoses: Decreased Cardiac Output, Activity Intolerance, Anxiety, Risk for Decreased Cardiac Tissue Perfusion. Outcomes: stable vital signs, tolerates activity, anxiety reduced. Interventions: monitor vitals, gradual activity progression, anxiety management.

Respiratory patient (pneumonia, COPD exacerbation). Diagnoses: Impaired Gas Exchange, Ineffective Airway Clearance, Anxiety, Activity Intolerance. Outcomes: SpO2 above 92%, productive cough, anxiety controlled. Interventions: respiratory monitoring, oxygen, suctioning, breathing techniques.

Diabetic patient. Diagnoses: Risk for Unstable Blood Glucose, Knowledge Deficit (diabetes management), Risk for Infection (especially if wound present), Powerlessness/Anxiety. Outcomes: stable glucose, verbalizes management plan, signs of healing. Interventions: blood glucose monitoring, medication administration, education, wound care.

Stroke patient. Diagnoses: Impaired Physical Mobility, Self-Care Deficit, Risk for Aspiration, Impaired Verbal Communication, Caregiver Role Strain. Outcomes: improved mobility, performs ADLs with assistance, swallowing safety. Interventions: PT consult, swallowing assessment, assistive devices, family education.

Mental health admission. Diagnoses: Risk for Self-Directed Violence, Anxiety, Impaired Coping, Powerlessness, Hopelessness. Outcomes: safety maintained, verbalizes coping strategies, demonstrates improvement in mood. Interventions: suicide assessment, therapeutic communication, safety planning, medication compliance, group therapy.

End-of-life/palliative care. Diagnoses: Acute/Chronic Pain, Anticipatory Grieving, Spiritual Distress, Compromised Family Coping, Powerlessness. Outcomes: comfort maintained, family supported, spiritual needs addressed. Interventions: comfort measures, family communication, spiritual support, advance directive discussions.

Tips for managing care plan workload.

Build templates. Save reusable templates for common diagnoses. Customize for each patient. Saves enormous time.

Use ATI study materials. ATI's Nursing Care Plans Made Incredibly Easy. ATI's Mental Health Care Plans. ATI's Pediatric Care Plans. Aligned with their templates.

Pearson Nursing Care Plans (11th edition). Comprehensive collection. ATI-compatible format. Excellent reference.

NANDA-I Nursing Diagnoses 2024-2026. Official source. Every nursing student should have current edition.

NIC and NOC manuals. Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC). Reference for interventions and outcomes. Cited in care plans.

Study groups. Work on care plans with classmates. Different perspectives. Share template ideas.

Clinical instructor feedback. Submit early drafts if instructor allows. Apply feedback. Maintain rapport.

Time management. Block dedicated time for care plans. Don't try to do them in 30-minute windows. Concentration matters.

Don't procrastinate. Start care plan day of clinicals when memory is fresh. Add details as you remember them. Final review and edit before submission.

Self-care. Care plans are demanding. Take breaks. Eat well. Sleep enough. Quality matters more than quantity of time.

Final thoughts. The ATI care plan template is a structured way to practice the nursing process — assessment, diagnosis, planning, implementation, evaluation. Done well, it builds the analytical thinking that defines competent nursing practice.

Approach each care plan as a chance to deepen your patient understanding. Don't just fill in boxes — think about why each section matters. Why this diagnosis for this patient? Why this outcome? Why these interventions? Care plans force structured thinking that translates to better clinical care.

Master NANDA-I language. Learn the official diagnosis labels by heart. The three-part diagnosis format (problem, related to, as evidenced by) is your foundation. SMART goals connect diagnoses to measurable outcomes.

Build your reference library. Pearson Nursing Care Plans, ATI's care plan books, NANDA-I, NIC, and NOC manuals are foundational. Bookmark online resources. Build a personal collection of templates for common scenarios.

Practice efficiency. First care plans take hours; experienced students complete them in 1-2 hours. Reuse templates. Build standardized interventions. Customize for each patient but don't reinvent the wheel.

Above all, take the work seriously. Care plans aren't just assignments — they're practice for real nursing. The patients you'll care for in your career will benefit from the careful, evidence-based thinking these templates demand. Embrace the rigor. Future you, and your future patients, will thank you.