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Assessment Provided all pertinent Fail to identify the Fail to identify the
1. Provides subjective data (chief compliant and history of data related to all nursing pertinent data pertinent data
present illness) diagnosis but also related to some related to all
2. Includes relevant history that supports the nursing diagnosis. includes data not related nursing diagnosis. nursing diagnosis.
3. Provides the objective data (clinical manifestations obtained Meets all to nursing diagnosis. May also include Assessment is
the criteria data that does not incomplete or
by physical assessment)
relate to nursing include data that do
4. Presents current laboratory findings and diagnostic findings diagnosis. not relate to
that supports the nursing diagnosis. nursing diagnosis.
5. The subjective and objective assessment strongly supports the
nursing diagnosis.
Diagnosis All nursing diagnosis are Some diagnosis are
6. Identify the priority/ actual and potential nursing problem. suitable for patient & not suitable for
All diagnosis are
7. Problem identified is relevant to patient’s condition Meets all
ordinal level & diagnosis patient. Also some
not suitable, are not
8. Nursing diagnosis is derived from NANDA and complete is NANDA approved, but diagnosis are not
the criteria be NANDA and
(problem, etiology, signs and symptoms). does not include all parts be NANDA & may
incomplete.
or information is listed in not include all
wrong part of diagnosis. parts.
Planning Goal statement is patient Some goal All goal statement
9. Derives goal from problem statement of nursing diagnosis or family centered & statement are not are not patient or
10. Demonstrated direct resolution of the problem contains at least 1 patient or family family oriented &
Meets all
11. Goals are SMART (specific, measurable, attainable, realistic measurable criteria or a oriented & may not may not have
the criteria
and time – bounded). target date/time. have measurable measurable criteria
criteria or a target or a target
date/ time. date/incomplete.
Taibah University جامعة طيبة
Al-Madinah Al-Munawara المدينة المنورة
Kingdom of Saudi Arabia المملكة العربية السعودية
College of Nursing كلية التمريض
Medical Surgical Department قسم الجراحة الطبية