DA Form 3888-2: Nursing Care Plan Guide & PDF Download

DA Form 3888-2: Nursing Care Plan Guide & PDF Download – DA Form 3888-2, titled “Medical Record – Nursing Care Plan,” was issued in June 1991 by the Department of the Army. It is used with DA Form 3888 (Nursing History and Assessment) and other forms like DA Form 3888-3 (Nursing Discharge Summary) to document the full nursing process.

For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General (OTSG). It serves as a permanent part of the inpatient treatment record (ITR).

Nurses use it to translate assessment data into actionable plans, including nursing diagnoses/problems, expected outcomes (goals), interventions, and evaluations. It promotes patient-centered care in Army hospitals and aligns with broader DoD health record standards.

Purpose and Importance in Army Nursing

The primary purpose of DA Form 3888-2 is to document identified nursing care problems (or nursing diagnoses), associated goals, discharge considerations, and patient/family education needs.

Key benefits include:

  • Providing a clear roadmap for all care team members.
  • Supporting continuity of care during shifts, transfers, or discharges.
  • Serving as a legal and quality assurance document.
  • Facilitating evaluation of nursing interventions and patient progress.
  • Helping calculate patient acuity and support research/education efforts.

In military healthcare, standardized documentation like this ensures high-quality, evidence-based care for service members, families, and other beneficiaries while meeting regulatory and accreditation requirements.

Key Sections of the DA Form 3888-2

The form features a structured table format with these main columns (instructions require numbering and initialing each entry):

  • Date Identified — When the problem/diagnosis was noted.
  • RN Initials — Responsible registered nurse.
  • # — Sequence number for the problem.
  • Problems (Nursing Diagnoses) — Patient issues, often drawn from standardized categories (e.g., NANDA-inspired, referencing Marjory Gordon’s patterns like Health Perception-Management, Activity-Exercise, Nutritional-Metabolic, etc.).
  • Expected Outcomes (Goals) — Measurable, patient-specific goals.
  • Date Accomplished/Revised — Tracking progress or updates.

Additional sections cover:

  • Discharge Considerations — Patient/family teaching, follow-up needs, etc.
  • Patient Identification — Name, grade, facility details (standard for medical records).

The reverse side continues the table and includes a helpful Nursing Diagnostic Category Guidelines reference listing common issues across patterns (e.g., Activity Intolerance, Impaired Skin Integrity, Anxiety, Knowledge Deficit).

How to Complete DA Form 3888-2: Step-by-Step Guidance?

  1. Enter Patient Identification — Complete all required fields accurately.
  2. Identify Problems/Diagnoses — Base on assessment (from DA Form 3888). Use clear, standardized language.
  3. Set Expected Outcomes — Make goals SMART (Specific, Measurable, Achievable, Relevant, Time-bound).
  4. Document Interventions — Often linked with DA Forms 4677/4678 (Therapeutic Documentation Care Plans).
  5. Evaluate and Revise — Record dates when goals are met or plans updated. Use nursing notes (e.g., SF 510) for detailed progress.
  6. Discharge Planning — Note education and post-discharge needs early.
  7. Sign and Date — RNs must authenticate entries per AR 40-66 rules.

Tip: If no specific problems are identified on admission, document this explicitly. Always follow local MTF policies for overprints or electronic equivalents.

Integration with the Nursing Process and Other Forms

DA Form 3888-2 fits into the broader nursing process:

  • Assessment → DA Form 3888.
  • Diagnosis/Planning → DA Form 3888-2.
  • Implementation → DA Forms 4677/4678 and SF 510 Nursing Notes.
  • Evaluation → Ongoing on the care plan + discharge summary (DA Form 3888-3).

This integration ensures comprehensive documentation that supports seamless handoffs and high standards of care in Army MTFs.

Download DA Form 3888-2 PDF

Access the official fillable version here:
Download DA Form 3888-2 PDF

Always use the most current official source from Army Publishing Directorate (armypubs.army.mil) for compliance.

Best Practices for Nursing Care Plans in Military Healthcare

  • Keep plans current, individualized, and interdisciplinary.
  • Focus on measurable outcomes for effective evaluation.
  • Incorporate patient and family education throughout.
  • Ensure HIPAA/privacy compliance and proper authentication.
  • Use the form to support Joint Commission-aligned quality improvement in MTFs.

Proper use of DA Form 3888-2 strengthens documentation, improves patient outcomes, and upholds the professional standards of Army nursing.

For full guidance, consult AR 40-66: Medical Record Administration and Healthcare Documentation and your local MTF nursing policies. This form remains a foundational tool in U.S. Army medical records for delivering excellent, patient-focused care.