Care P :

Description

Points Received/

Total Points Possible

Comments

Diagnosis #1

Diagnosis #2

Totals

Patient Information

· Complete patient demographics, pregnancy and delivery information

____/ 2

Medications:

· Identify current meds and purpose

____/ 1

Nursing Diagnosis (Include ALL 3 Dx):

· Reflects the primary diagnosis

· Priorities diagnoses appropriately

· Appropriate for patient scenario

· In acceptable NANDA format

· Includes all parts stem, R/T, AEB

____/ 3

Development of diagnoses

#1

#2

Assessment:

· Appropriate for chosen diagnosis

· Includes objective & subjective historical support diagnosing data

____/3

+ ____/3

= ___/ 6

Patient Outcomes:

· Specific to the patient diagnosis

· Contains the following 4 criteria:

measurable, attainable, realistic, and timed

· All criteria present for patient’s expected outcome

____/3

+ ____/3

= ____/ 6

Intervention/Implementation:

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· # of interventions is appropriate to help pt./ family meet their outcomes

____/3

+ ___/3

= ____/ 6

Evaluation:

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

____/3

+ ___/3

= ____/ 6

Total Points

____/ 30

Passing grade = 22.5 / 30 (75%)