Amanda, Davies

Criteria for Assessment

Mastery

10 points

Competent

9 points

Needs Improvement

8 point

Total

Points

PATIENT INFORMATION

· Background

· Reason for visit or hospitalization

· Social history

Includes all criteria

Missing or incomplete data for one criterion

Missing or incomplete data for two or more criteria

/10

SUBJECTIVE

· Patient-provided data:

· Statements or questions

· Complaints or concerns

Complete; includes all pertinent subjective information

Partial summary of pertinent subjective information

Poorly organized and/or limited summary of pertinent subjective information

/10

OBJECTIVE

· Physical assessment data

· Interval test data

· Lab or blood work data

· Other objective data

· Current orders, including medications

Complete; includes well-organized summary of pertinent objective data

Includes a mostly complete summary of pertinent objective data; may be missing one data point and/or may be lacking in organization

Poorly organized and/or limited summary of pertinent objective data

/10

ASSESSMENT

· Interprets information from previous S and O sections:

· Primary Medical diagnosis and three nursing diagnoses

· Nursing diagnoses are prioritized

· Treatment goals for each nursing diagnosis are identified

· Accurately interprets information from S and O sections

· Lists four nursing diagnoses with appropriate prioritization

· Identifies appropriate treatment goals for each nursing diagnosis

· Interprets most information from S and O sections accurately; generates a mostly complete list of nursing diagnoses; most are appropriately prioritized

· Identifies appropriate treatment goals for most nursing diagnoses

· Does not accurately interpret information from S and O sections; incomplete list of nursing diagnoses; is not prioritized appropriately

· May not identify appropriate goals for problems/diagnoses

/10

PLAN

· Summarizes nursing treatment plan

· Prioritizes nursing interventions and provides explanation for priority order

· Summarizes overall nursing treatment plan clearly and concisely

· Prioritizes specific interventions and explains priority order

· Includes a complete list of all pertinent interventions with all relevant information, including complete medication information, if applicable

· Summarizes overall treatment plan

· Lists interventions but may not accurately prioritize or explain priority order

· Lists interventions but may be missing 1 or 2 pertinent ones; may not include complete medication information

· Incomplete summary of treatment plan

· Incomplete list of interventions; lack of prioritization or explanation of priority order

· Missing 3 or more pertinent interventions

/10

PATIENT NEEDS

Identifies patient needs and provides specific information about each:

· Case management or discharge planning

· Patient education

· Psychosocial, spiritual, and/or family support

Adequately addresses specific patient needs related to case management or discharge planning; patient education; psychosocial, spiritual, and/or family support

Addresses all but one specific patient needs

Missing two or more specific patient needs

/10

REFLECTION

· Feelings about experiences in clinical; strengths and areas for growth

· Integration into healthcare team with examples; relationship with clinical partners or preceptors

· Characterizes transitioning experience; helping/hindering transition; plan for forward progress

Addresses all prompts thoroughly and completely; provides specific examples and descriptions

Addresses all prompts but may be missing a specific example or description

Does not address all prompts and/or missing specific examples or descriptions

/10

WRITING

Clear writing and organization; no more than two spelling or grammatical errors

Adequate writing and organization; no more than three spelling or grammatical errors

Writing lacks clear organization and/or more than four spelling/grammatical errors

/10

ORAL PRESENTATION

Mastery

Competent

Needs Improvement

10 points

9 points

8 points

CONTENT

Patient Information, Subjective, Objective, Assessment, Plan, Patient Needs

Addresses each section in a concise and knowledgeable manner; can answer questions succinctly if appropriate

Addresses most sections; may be missing complete information in 1 or 2 areas

Missing complete information in 3 or more areas

/10

5 points

4 points

3 points

ELOCUTION

Excellent oral presentation skills: professional and clear speech; appropriate volume and pace of speaking

Adequate oral presentation skills; may need to be reminded to speak clearly, increase volume, or slow down

Oral presentation skills need improvement; may be lacking in professionalism; speech may be difficult to hear or understand

/5

5 points

4 points

3 points

TIMING

10 minutes or less

More than 10 but less than 12 minutes

More than 12 minutes

/5

TOTAL POINTS:

/100