This document outlines the grading criteria for a nursing care plan assessment tool. It is divided into 8 sections that are scored individually: 1) Assessment, 2) History of present illness, 3) History of past illness, 4) Pathophysiology, 5) Problem identification and prioritization, 6) Nursing care plan, 7) Reference list, and 8) Form and style. Each section contains specific elements that are scored on a scale of 1 to 3 based on completeness, accuracy, appropriateness, and other factors. The total possible score is 50 points.
This document outlines the grading criteria for a nursing care plan assessment tool. It is divided into 8 sections that are scored individually: 1) Assessment, 2) History of present illness, 3) History of past illness, 4) Pathophysiology, 5) Problem identification and prioritization, 6) Nursing care plan, 7) Reference list, and 8) Form and style. Each section contains specific elements that are scored on a scale of 1 to 3 based on completeness, accuracy, appropriateness, and other factors. The total possible score is 50 points.
This document outlines the grading criteria for a nursing care plan assessment tool. It is divided into 8 sections that are scored individually: 1) Assessment, 2) History of present illness, 3) History of past illness, 4) Pathophysiology, 5) Problem identification and prioritization, 6) Nursing care plan, 7) Reference list, and 8) Form and style. Each section contains specific elements that are scored on a scale of 1 to 3 based on completeness, accuracy, appropriateness, and other factors. The total possible score is 50 points.
E SCORE A. Completeness of data 1 B. Accuracy of data 1 C. Proper identification of care concerns 1 D. Truthfulness of data 1 II. HISTORY OF PRESENT ILLNESS A. Correct identification of chief complaint 1 B. Completeness of information 1 C. Complete chronology of progress of the disease/problem 1 III. HISTORY OF PAST ILLNESS A. Past history a. 1. Completeness of information 1 B. Family history b. 1. Specific presentation of family history 1 b. 2. Completeness of information 1 C. Social history c. 1. Accuracy and completeness of information 1 IV. PATHOPHYSIOLOGY A. Identification of risk/predisposing factors 1 B. Detailed presentation of the progress of the condition 1 b. 1. Signs and symptoms identified 1 b. 2. Identify proper Cause and Effect relationship 1 b. 3. Integration of relevant diagnostic findings and 1 procedures/treatment b. 4. Appropriate linkages to correct nursing diagnosis 1 V. PROBLEM IDENTIFICATION AND PRIORITIZATION A. Complete and correct identification of nsg problems and nsg dx 2 B. Prioritization b. 1. Prioritization of problem 1 b. 2. Justification 2 b. 3. Proper clustering of identified problems 1 VI. NURSING CARE PLAN A. Cues/data a. 1. Appropriateness of cues to the nursing diagnosis 2 A. 2. Completeness of cues presented S and O data 2 B. Explanation of the problem b. 1. Present a scientific explanation of the problem as related to the 2 patient’s condition b. 2. Clear definition of the problem 1 C. Objectives c. 1. SMART 1 c. 2. Objectives are directly addressing the problems and the cause c. 2. 1. LTO- problem that can be resolved after 72 hours 2 c. 2. 2. STO- problem that can be resolved in 72 hours 1 D. Nursing Interventions d. 1. Appropriateness of interventions in resolving the problems 3 d. 2. Proper clustering of interventions 1 d. 3. Comprehensive identification of interventions 2 E. Rationale e. 1. Scientific basis of rationale 2 e. 2. Appropriateness of rationale to the intervention of the patient’s 2 condition F. Evaluation f. 1. Appropriateness of evaluation criteria 2 f. 2. Clear presentation of actual evaluation of patient’s condition 2 VII. REFERENCE LIST A. Use of 7th ed APA format in citation and referencing 1 VIII. FORM AND STYLE A. Grammar 1 B. Organization 1 C. Neatness 1 TOTAL 50