Care Plan Rubric Scores PDF

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Summary

Rubric for care plans...

Description

TEXAS WOMAN’S UNIVERSITY COLLEGE OF NURSING N3025 NURSING CARE PLAN Rubric

*A student must pass the care plan with a grade of 80 or above Patient Data Collection

Incomplete (0) No patient Data given

Physical Assessment Form Includes pertinent labs, subjective, objective and historical data that support actual or risk for nursing diagnosis.

Diagnosis Includes the most appropriate diagnosis for patient and ordinal number that includes all appropriate parts (stem, related to or R/T, and as evidenced by AEB for actual diagnosis) and is NANDA approved.

Planning (Goal Setting) Includes a patient or family goal that is most appropriate for the patient/family and the nursing diagnosis. Goal should be measurable by at least two criteria and have a target date or time.

Implementation (Interventions Includes interventions or nursing actions that directly relate to the patient's goal, that are specific in action and frequency, are labeled "I" for independent and "C" for collaborative, and include a referenced rationale with page number (if

Below Average (5)

Average (8)

Patient data is collected and greater Patient data is collected in a timely manner and 2-4 important than 4 important elements are elements are missing missing

Above Average (10) Patient data is collected in a timely manner and all elements are noted Above Average (10)

Incomplete (0)

Below Average (5)

Average (8)

Assessment portion is incomplete. Does not include lab results and pertinent subjective and objective data

Does not include all pertinent data related to nursing diagnosis. May also include data that does not relate to nursing diagnosis. Missing important labs with rationales. Subjective and objective data do not support nursing diagnosis

Includes all pertinent data related to nursing diagnosis, but also includes data not related to nursing diagnosis. Labs present with inappropriate rationale. Subjective and objective data support nursing diagnosis with inconsistencies

Incomplete (0)

Below Average (5)

Average (8)

Above Average (10)

Diagnosis is appropriate for patient and ordinal level, and diagnosis is NANDA approved, but does not include all parts or information is listed in wrong part of diagnosis. Only list 2-4 appropriate diagnosis and select one priority “actual” diagnosis.

Diagnosis is appropriate for patient and ordinal level, and diagnosis is NANDA approved. Diagnosis also includes all parts and information is listed in correct part of diagnosis. Includes 5 diagnosis and selects one "priority" and "actual” diagnosis.

Diagnosis portion is incomplete.

Incomplete (0) Goal portion is incomplete.

Incomplete (0) Interventions portion is incomplete.

Diagnosis is not appropriate for patient and ordinal level (first diagnosis, second diagnosis, etc). May also not be NANDA and may not include all parts. Only list 1-2 appropriate diagnosis and does not select a priority “actual” diagnosis.

Includes all pertinent data related to nursing diagnosis and does not include data that is not related to nursing diagnosis. Labs are noted with appropriate rationales. Subjective and objective data support nursing diagnosis.

Above Average (20)

Below Average (10)

Average (15)

Goal statement is not patient or family oriented and does not have measurable criteria or a target date or time. Includes 1 STG or 1 LTG not both

Goal statement is patient or family oriented, and contains at least one measurable criteria or a target date/time. Includes 1 STG and/or 1 LTG.

Below Average (10)

Average (15)

Above Average (20)

Interventions portion contains adequate number of interventions to help patient/family meet goal, but interventions may not be specific, labeled or listed with rationales.

Interventions portion contains adequate number of interventions to help patient/family meet goal, and interventions are specific in action and frequency, labeled with "I" or "C" and are

Interventions portion does not include adequate number of interventions to help patient/family meet goal. Interventions may also not be specific, labeled or listed with

Goal statement is patient or family oriented, and contains two measurable criteria and a target date or time. Includes 1 STG & 1 LTG.

rationales.

applicable). Number of interventions should be appropriate to help patient or family meet their goal. Evaluation Includes data that is listed as criteria in goal statement. Based on this data, goal is determined to be met, partially met, or not met. If goal was not met or partially met, plan of care is revised or continued and a new evaluation date/time is set.

Writing Style / Professional Care Plan

Incomplete (0)

listed with referenced rationales.

Below Average (10)

Average (15)

Evaluation portion does not contain data that is listed as criteria in goal statement. May also not describe goal as met, partially met, or not met. May also not include revision or new evaluation date/time. Statement of goal achievement or non-achievement is not described.

Evaluation portion does contain data that is listed as criteria in goal statement, but does not describe goal as met, partially met, or not met. May also not include revision or new evaluation date/time. Statement of goal achievement or non-achievement is not described.

Incomplete (10)

Below Average (5)

Average (8)

Multiple grammatical and sentence structure errors.

Great than 4 1-4 grammatical and sentence structure errors.

1-4 grammatical and sentence structure errors.

Evaluations portion is incomplete.

Good (20) Evaluation portion does contain data that is listed as criteria in goal statement. Does describe goal as met, partially met, or not met. If goal was partially met or not met, includes revision and/or new evaluation date/time. Statement of goal achievement or non-achievement is described.

Good (10) No errors in professional writing skill...