0 pts
2.5 pts
5 pts
7.5 pts
10 pts
Includes at least 2 subjective data in quotes and 2 objective data/historical data that support actual or risk for nursing diagnosis.
Includes an appropriate or the Highest Priority nursing diagnosis for patient/resident that includes all appropriate parts (stem, related to or R/T, and as evidenced by AEB for actual diagnosis) and is NANDA approved and does not use any medical diagnosis.
Includes goal that is most appropriate for the patient/family and the nursing diagnosis. Goal should be SMART (specific, measurable, attainable, realistic, and time frames) measurable criteria and have a target date or time.
For goal you must include two (2) nursing interventions and rationales for each that directly relate to the resident/patient's goal (plan) and that are specific in action (SMART)
Evaluation is of the GOAL. It includes data that is listed as criteria in each goal statement. Based on this data, goal is determined to be met, partially met (still in progress), or not met. If goal was not met or partially met, plan of care is revised by continuing current interventions and adding a new intervention with rationale and a new evaluation date/time is set. If goal met state "goal met", date, and continue plan of care.