Care plan and Concept Map for Medical-Surgical (Nursing)
Pearl_shun
N210MajorNursingCarePlanRubric.docx
N210
2 CCC Care Plan Rubric Level two
NURSING CARE PLAN RUBRIC
Rubric Evaluation for Nursing Care Plan Sheet
|
Criteria |
Satisfactory 5 points |
Needs Improvement 3 points |
Unsatisfactory 2 points |
Not Evident/Not Attempted |
|
Client Data Collection and documentation of client data |
Collects and documents appropriate client data accurately and completely
populated the entire data collection tool with pertinent client information
|
Collects and documents appropriate client data partially accurate and/or partially complete populated 75% of the data collection tool with pertinent client information
|
Collects and documents appropriate client data both inaccurately and incompletely Student populated less than 50% of the data collection tool with pertinent client information
|
Data not collected |
|
Relate pathophysiology of disease to client’s assessment finds, medications, laboratory, and diagnostic test results |
Includes complete evaluation of pathophysiology, risks, meds, diagnostics, and assessment. |
Most data demonstrated, but missing some critical points. |
Missing many factors; incomplete but made an effort |
No effort made |
|
Nursing Process |
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Formulate a nursing diagnosis |
Student’s nursing diagnosis is written to NANDA standards and supported by data collected and is a 3 – part diagnosis
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Student’s 3-part nursing diagnosis is written to NANDA standards but was not supported by data collected. OR Student’s nursing diagnosis is not written to NANDA standards but was supported by data collected. partially accurate and/or partially complete
|
Nursing diagnosis is not written to NANDA standards and is not supported by data collected OR Only 2 part nursing diagnosis provided
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No Nursing Diagnosis provided |
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Develop a short-term (shift) and long term goals (>48 hours)/outcomes |
Goals / outcome is applicable to nursing diagnosis and contains the elements of SMART (specific, measurable, attainable, related, and time) |
Goal / outcome is applicable to nursing diagnosis but does not contain elements of SMART (specific, measurable, attainable, related, and time) |
Goals / outcome are not applicable to nursing diagnosis and may or may not contain elements of SMART (specific, measurable, attainable, related, and time) |
NO goals/outcomes identified |
|
Planned interventions |
Five (5) OR more interventions with relevant rationales based on data collected, nursing diagnosis, and short-term goal / outcome and is prioritized.
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At least Three (3) interventions with relevant rationales based on data collected, nursing diagnosis, and short-term goal / outcome and are not prioritized OR Interventions listed are not relevant based on data collected, nursing diagnosis, and short-term goal / outcome |
Interventions listed are less than 3 OR listed interventions do not have a rationale is not supported by data collected OR are not written to standards of nursing practice
|
No interventions and rationale are listed |
|
Medications Identification of medications and related information
Corresponding Medication Card completed |
Identifies medications and related information: names, actions, side-effects, and nursing responsibilities
accurately and completely
|
Identifies some medications and related information some names, actions, side-effects, and nursing responsibilities Or all names, actions, side-effects, and nursing responsibilities associated with only some medications And/or only Some medication cards completed
partially accurate and/or partially complete |
Identifies medications and related information: not able to articulate the names, actions, side-effects, and nursing responsibilities
both inaccurately and incompletely
|
NO medications listed, and no corresponding medication cards completed |
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Evaluation Evaluation of the client after implementing the plan and nursing interventions |
Evaluation criteria listed for all interventions |
Evaluation criteria listed for some interventions |
Inappropriate Evidence criteria listed for some interventions |
No Evidence criteria listed |
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Documentation Documentation of nursing note per assigned format |
Documents nursing note per assigned format accurately and completely objective and subjective data to accordance with ANA standards
|
Documents objective and subjective data not in accordance with ANA standards
|
Student did not document or documentation is limited
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Unable to follow, not concise to client care |
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Technical Paper Elements |
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APA formatting |
Care plan journal article is documented using APA formatting for references and In-text citations |
Care plan journal article is documented using APA formatting for references OR In-text citations |
Care plan journal article is documented but does not use APA formatting for references OR In-text citations |
NO use of APA formatting for references and in-text citations |
|
Journal Article |
Summarizes the article from a professional journal related to plan of care and relates to the care of this client |
Uses an article to support care interventions from a nursing journal but does not support care or interventions and/or does not relate to this client |
Article does not relate to plan of care, OR is out of date (>5 years) |
No article or summary is provided |
Points ____ Points ____ Points ____
Grading Instructions:
Grading Rubric for Major Care Plan:
50 – 45 Excellent
40 - 44.9 Satisfactory
25-39.9 Needs Improvement
<20-24.9 Unsatisfactory
Total Points =__________
Grading Scale:
Excellent: 90-100%
Satisfactory: 80-90%
Needs improvement: 79%-50% or less
Unsatisfactory: 0- 50%
NOTE: Failure to submit the required clinical assignments may result in a zero.
Rev 8/21
