Nursing care plan

CC rubric that provides an objective basis for creating and grading care plans. Score from 0-100%.

Incomplete 5 pts

Poor 10 pts

Fair 15 pts

Good 20 pts

Assessment

Includes subjective, objective and historical data that support actual or risk for nursing diagnosis.

Incomplete

Assessment portion is incomplete.

Poor

Does not include all pertinent data related to nursing diagnosis. May also include data that does not relate to nursing diagnosis.

Fair

Includes all pertinent data related to nursing diagnosis, but also includes data not related to nursing diagnosis.

Good

Includes all pertinent data related to nursing diagnosis and does not include data that is not related to nursing diagnosis.

Diagnosis

Includes the most appropriate diagnosis for patient and ordinal number that includes all appropriate parts (stem, related to or R/T, and as evidenced by AEB for actual diagnosis) and is NANDA approved.

Incomplete

Diagnosis portion is incomplete.

Poor

Diagnosis is not appropriate for patient and ordinal level (first diagnosis, second diagnosis, etc). May also not be NANDA and may not include all parts.

Fair

Diagnosis is appropriate for patient and ordinal level, and diagnosis is NANDA approved, but does not include all parts or information is listed in wrong part of diagnosis.

Good

Diagnosis is appropriate for patient and ordinal level, and diagnosis is NANDA approved. Diagnosis also includes all parts and information is listed in correct part of diagnosis.

Planning (Goal Setting)

Includes a patient or family goal that is most appropriate for the patient/family and the nursing diagnosis. Goal should be measurable by at least two criteria and have a target date or time.

Incomplete

Goal portion is incomplete.

Poor

Goal statement is not patient or family oriented and may not have measurable criteria or a target date or time.

Fair

Goal statement is patient or family oriented, and contains at least one measurable criteria or a target date/time.

Good

Goal statement is patient or family oriented, and contains two measurable criteria and a target date or time.

Implementation (Interventions

Includes interventions or nursing actions that directly relate to the patient's goal, that are specific in action and frequency, are labeled "I" for independent and "C" for collaborative, and include a referenced rationale with page number (if applicable). Number of interventions should be appropriate to help patient or family meet their goal.

Incomplete

Interventions portion is incomplete.

Poor

Interventions portion does not include adequate number of interventions to help patient/family meet goal. Interventions may also not be specific, labeled or listed with rationales.

Fair

Interventions portion contains adequate number of interventions to help patient/family meet goal, but interventions may not be specific, labeled or listed with rationales.

Good

Interventions portion contains adequate number of interventions to help patient/family meet goal, and interventions are specific in action and frequency, labeled with "I" or "C" and are listed with referenced rationales.

Evaluation

Includes data that is listed as criteria in goal statement. Based on this data, goal is determined to be met, partially met, or not met. If goal was not met or partially met, plan of care is revised or continued and a new evaluation date/time is set.

Incomplete

Evaluations portion is incomplete.

Poor

Evaluation portion does not contain data that is listed as criteria in goal statement. May also not describe goal as met, partially met, or not met. May also not include revision or new evaluation date/time.

Fair

Evaluation portion does contain data that is listed as criteria in goal statement, but does not describe goal as met, partially met, or not met. May also not include revision or new evaluation date/time.

Good

Evaluation portion does contain data that is listed as criteria in goal statement. Does describe goal as met, partially met, or not met. If goal was partially met or not met, includes revision and/or new evaluation date/time.