5 pts
10 pts
20 pts
Includes subjective, objective and l data that support actual or risk for nursing diagnosis.
Includes the most appropriate diagnosis for patient includes all appropriate parts 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 is Specific, Measurable, Attainable, Realistic, and Time-Bounded
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.