Professional Documents
Culture Documents
I. ASSESSMENT: 30% A. Subjective & objective date to support nursing diagnosis including client history, physical assessment findings, lab findings & any other pertinent subjective and/or objective data. II. ANALYZING/NURSING DIAGNOSIS: 20% A. Prioritized nursing diagnosis supported by clearly stated subjective & objective data B. Contains statement regarding client problem & etiology of problems. May also contain signs & symptoms III. PLANNING: 10% A. Goal is derived form problem statement of nursing diagnosis. B. Client goal supported by data and nursing diagnosis. C. Goal statement contains subject, verb, criteria & time frame. (Must be measurable) D. Goal is realistic for client.
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IV. IMPLEMENTATION: 30% A. Interventions are derived from etiology of nursing diagnosis & will help client achieve goal. 8 B. Intervention statement contains who, what, when, where, & how often (frequency including times when applicable) 14 C. Rationale (including source & page #) for each intervention. 8 V. EVALUATION: 10% A. Evaluation statement includes whether goal was met, partially met, or not met, compared to outcome criteria listed in goal statement. Lists evidence to support evaluation statement. B. Identifies factors which prevent goal from being accomplished. Includes recommendations to facilitate the accomplishment of the goal.
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Total _____ Grade _____ (Anything below 75 is unsatisfactory) Final Grade:_________ Date:______ Leaders signature:____________________