5 pts
10 pts
15 pts
20 pts
Includes subjective, objective and historical data that support actual or risk for nursing 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.
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.
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 applicable). Number of interventions should be appropriate to help patient or family meet their goal.
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.