2.5 pts
5 pts
7.5 pts
10 pts
Includes subjective, objective and historical data that support actual or risk for nursing diagnosis.
Includes appropriate diagnosis for patient 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 goal that is most appropriate for the patient/family and the nursing diagnosis. Goal should be measurable criteria and have a target date or time.
Includes five nursing interventions and rationales that directly relate to the patient's goal and that are specific in action
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.