NURSING CARE PLAN RUBRIC NAME: COURSE: ________DATE: ________________ CLIENT INITIALS: CLIENT DISEASE/DISORDER: _____________________ 4 3 2 1 Points (Excellent) ( Good) (Minimally Competent) (Unacceptable) CRITERIA 10 8 5 3 1.History of Present HPI explained in detail with HPI explained in some detail HPI explained in limited HPI details limited with poor Illness, Physical accurate and in-depth with moderate understanding detail with marginal understanding of Assessment, & understanding of chief of chief complaint and understanding of chief complaint and presenting Diagnostic tests/ complaint and presenting presenting signs/symptoms complaint and presenting signs/symptoms does not signs/symptoms supported by somewhat supported by signs/symptoms vaguely support medical diagnosis, procedures physical assessment; physical assessment; supported by physical Identifies assessments identifies 5-6 key assessments identifies 3-4 key assessments assessment; parameters not relevant to parameters relevant to medical parameters relevant to medical identifies 1-2 key medical diagnoses, no diagnoses with APA diagnosis with references. assessments parameters references cited. references. relevant to medical diagnosis, no references Past medical history detailed Past medical history given Past medical history given No past medical history given 2. Past Medical & Surgical History, with full explanation of with partial explanation of with minimal explanation of without explanation; no Pathophysiology Pathophysiology for each identified preexisting medical identified preexisting medical preexisting medical diagnosis diagnosis & accurate details diagnoses& explanation diagnoses & few details identified or with specific detail related to accurate with some detail related to the client’s history explanations inaccurate and the client’s history and related to the client’s history and symptoms without not related to the client’s symptoms. and symptoms. references. history and symptoms without APA references References references.
NURSING CARE PLAN RUBRIC NAME: COURSE: ________DATE: ________________ CLIENT INITIALS: CLIENT DISEASE/DISORDER: _____________________ 4 (Excellent) 3 ( Good) 2 (Minimally Competent) 1 (Unacceptable) Points CRITERIA 10 8 5 3 1.History of Present Illness, Physical Assessment, & Diagnostic tests/ procedures HPI explained in detail with accurate and in-depth understanding of chief complaint and presenting signs/symptoms supported by physical assessment; identifies 5-6 key assessments parameters relevant to medical diagnoses with APA references. HPI explained in some detail with moderate understanding of chief complaint and presenting signs/symptoms somewhat supported by physical assessment; identifies 3-4 key assessments parameters relevant to medical diagnosis with references. HPI explained in limited detail with marginal understanding of chief complaint and presenting signs/symptoms vaguely supported by physical assessment; identifies 1-2 key assessments parameters relevant to medical diagnosis, no references HPI details limited with poor understanding of complaint and presenting signs/symptoms does not support medical diagnosis, Identifies assessments parameters not relevant to medical diagnoses, no references cited. 2. Past Medical & Surgical History, Pathophysiology Past medical history detailed with full explanation of Pathophysiology for each diagnosis & accurate details with specific detail related to the client’s history and symptoms. APA references Past medical history given with partial explanation of identified preexisting medical diagnoses& explanation accurate with some detail related to the client’s history and symptoms. References Past medical history given with minimal explanation of identified preexisting medical diagnoses & few details related to the client’s history and symptoms without references. No past medical history given without explanation; no preexisting medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without references.