Detailed and Detailed and Detailed or Not detailed or Not detailed or Introduction: specific specific, but Specific (not specific and specific and including all missing one both) and/or missing 1-2 missing more aspects aspect missing 2 aspects than 3 aspects mentioned in mentioned. aspects mentioned. mentioned. guidelines. mentioned Detailed and Detailed and Detailed or Not detailed or Not detailed or History: PMH specific specific, but Specific (not specific and specific and Treatments until including all missing one both) and/or missing 1-2 missing more admission aspects aspect missing 2 aspects than 3 aspects mentioned in mentioned. aspects mentioned. mentioned. guidelines. mentioned Extensive detail Detailed with Detailed but Detailed but Not detailed Pathophysiology Disease process, with causes and causes and without causes without causes and without and manifestations. manifestations or or causes, manifestations. Comparing your & comparison manifestations manifestations manifestations, patient to the of patient to OR and and classic classic comparisons comparisons comparisons. presentation. presentation. Detailed and Detailed and Detailed or Not detailed or Not detailed or Assessment: Complete Head to specific specific, but Specific (not specific and specific and Toe OR Mental assessment missing one both) and/or missing 1-2 missing more assessment. includes all aspect missing 2 aspects than 3 aspects aspects mentioned. aspects mentioned. mentioned. mentioned in mentioned guidelines. Detailed Detailed Detailed Unable to No related to Related treatments treatments treatments not identify treatment Treatment: Discuss treatments specific to specific to specific to the treatment mentioned. DURING your diagnosis, as diagnosis. diagnosis. related to care that are well as Could not diagnosis or specific to the treatment/tests identify care. diagnosis. important to relevant data care. 3 or + with 3 3 or + either 2 with 3 2 either 1 or less Nursing Care: Nursing diagnoses interventions incorrectly interventions incorrectly diagnosis. with at least 3 each and listed prioritized, or each and listed prioritized, or interventions each. by prioritization. with less than 3 by with less than 3 interventions. prioritization. interventions. Detailed Detailed Detailed Issue addressed Statement that Legal/Ethical: Legal/Ethical discussion of discussion of discussion of that is neither no Issue. L/E Issue, L/E L/E legal or ethical. issue existed. Actions taken (or actions taken (or without either without actions should have been should have actions taken or taken or taken). been taken), and application of application of Application of application of ANA Code of ANA Code of ANA Code of ANA Code of Ethics Ethics
Introduction: Detailed and specific including all aspects mentioned in guidelines. Detailed and specific, but missing one aspect mentioned. Detailed or Specific (not both) and/or missing 2 aspects mentioned Not detailed or specific and missing 1-2 aspects mentioned. Not detailed or specific and missing more than 3 aspects mentioned. History: PMH Treatments until admission Detailed and specific including all aspects mentioned in guidelines. Detailed and specific, but missing one aspect mentioned. Detailed or Specific (not both) and/or missing 2 aspects mentioned Not detailed or specific and missing 1-2 aspects mentioned. Not detailed or specific and missing more than 3 aspects mentioned. Pathophysiology Disease process, and manifestations. Extensive detail with causes and manifestations. Comparing your patient to the classic presentation. Detailed with causes and manifestations & comparison of patient to classic presentation. Detailed but without causes or manifestations OR comparisons Detailed but without causes or manifestations and comparisons Not detailed and without causes, manifestations, and comparisons. Assessment: Complete Head to Toe OR Mental assessment. Detailed and specific assessment includes all aspects mentioned in guidelines. Detailed and specific, but missing one aspect mentioned. Detailed or Specific (not both) and/or missing 2 aspects mentioned Not detailed or specific and missing 1-2 aspects mentioned. Not detailed or specific and missing more than 3 aspects mentioned. Related Treatment: Discuss treatments DURING your care that are specific to the diagnosis. Detailed treatments specific to diagnosis, as well as treatment/tests important to care. Detailed treatments specific to diagnosis. Detailed treatments not specific to the diagnosis. Could not identify relevant data Unable to identify treatment related to diagnosis or care. No related to treatment mentioned. Nursing Care: Nursing diagnoses with at least 3 interventions each. 3 or + with 3 interventions each and listed by prioritization. 3 or + either incorrectly prioritized, or with less than 3 interventions. 2 with 3 interventions each and listed by prioritization. 2 either incorrectly prioritized, or with less than 3 interventions. 1 or less diagnosis. Legal/Ethical: Legal/Ethical Issue. Actions taken (or should have been taken). Application of ANA Code of Detailed discussion of L/E Issue, actions taken (or should have been taken), and application of ANA Code of Detailed discussion of L/E without either actions taken or application of ANA Code of Ethics Detailed discussion of L/E without actions taken or application of ANA Code of Ethics Issue addressed that is neither legal or ethical. Statement that no issue existed.
nur4405-spr18.docx