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iRubric: Breckinridge Mid Term Care Plan Rubric

iRubric: Breckinridge Mid Term Care Plan Rubric

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Breckinridge Mid Term Care Plan Rubric 
Breckinridge Mid Term Care Plan Rubric
A rubric that provides an objective basis for creating and grading care plans from beginning nursing students in their first med/surg clinical. Score from 0-100%.
Rubric Code: B79244
By kreiselm
Ready to use
Public Rubric
Subject: Nursing  
Type: Assignment  
Grade Levels: Undergraduate

Powered by iRubric Nursing Care Plan Rubric
A rubric that provides an objective basis for creating and grading care plans from begining nursing students in their first med/surg clinical. Score from 0-100%.
  Not Done

0 pts

Incomplete

2.5 pts

Poor

5 pts

Fair

7.5 pts

Good

10 pts

Assessment

Includes at least 2 subjective data in quotes and 2 objective data/historical data that support actual or risk for nursing diagnosis.
Not Done

No subjective data in quotes and/or no objective/historical data.
Incomplete

Assessment portion is incomplete. Less than 2 quoted subjective data statements and/or less than 2 objective/historical data.
Poor

Subject and/or objective data does not include all pertinent data related to chosen nursing diagnosis. May also include subjective and/or objective data that does not relate to chosen nursing diagnosis.
Fair

Subjective and/or objective data includes all pertinent data related to chosen nursing diagnosis, but also includes data not related to chosen nursing diagnosis.
Good

Subjective and/or objective data includes all pertinent data related to chosen nursing diagnosis and does not include data that is not related to chosen nursing diagnosis.
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.
Not Done

Nursing Diagnosis not written in required format, is not of the highest prioroty, is missing, and/or inappropriate based on subjective and objective data and/or medical diagnosis.
Incomplete

Nursing Diagnoses portion is incomplete, may be missing r/t or AEB, may have used a medical diagnosis, and/or does not relate to subjective and objective data.
Poor

Diagnosis is not appropriate for resident/patient based on subjective and objective data resident/patients medical diagnosis, as well as ordinal level (priority diagnosis, second diagnosis, etc).May also not be NANDA and may not include all parts.
Fair

Diagnosis is appropriate based on subjective and objective data and medical diagnosis. Is NANDA approved, but may not include all parts or information (r/t or AEB), is listed in wrong part of diagnosis. May not be prioroty diagnosis
Good

Diagnosis is high priority and appropriate for resident/patient based on subjective and objective data as well as NANDA approved. Diagnosis also includes all parts and information is listed in correct part of diagnosis.
Planning (Goal Setting)

Includes 1 long term goal and short term 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.
Not Done

Does not have one long term and/or one short term goal.
Incomplete

Goal portion is incomplete. May be missing one or more of the SMART process.
Poor

Goal statement is not patient or family oriented and/or of priority, and may not have measurable criteria or a target date or time.
(SMART)
Fair

Goal statement is patient or family oriented, and contains at least one measurable criteria or a target date/time.
(SMART)
Good

Goal statement is patient or family oriented, high priority for diagnosis, and contains all measurable criteria of SMART
Implementation (Interventions

For the long term goal and the short term 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)
Not Done

Does not have the required two (2) interventions and rationales for the long and/or short term goal.
Incomplete

Interventions and/or Rationale portion is incomplete. May be missing one or more of the SMART process.
Poor

Intervention/Rationaldoes not include required two (2) interventions with rationales to help patient/family meet goal. Interventions may also be missing part of the SMART process, not labeled or not listed with rationales.
Fair

Intervention/Rational contains required number two (2) interventions with rationales to help patient/family meet goal. Interventions may also be missing part of the SMART process, not labeled or not listed with rationales.
Good

Intervention/Rational contains required number of interventions two (2) with rationales to help patient/family meet goal. All parts of the SMART process are used.
Evaluation

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.
Not Done

No evaluation completed or evaluation is not of the stated goals.
Incomplete

Evaluations portion is incomplete. Evaluator can tell if goals met, or not met, missing data as listed in requirements.
Poor

Evaluation portion does not contain data that is listed as criteria in goal statement. May also not describe goal as met, partially met, or not met. May also not include revision or new evaluation date/time.
Fair

Evaluation portion does contain data that is listed as criteria in goal statement, but does not describe goal as met, partially met, or not met. May also not include revision or new evaluation date/time.
Good

Evaluation portion does contain data that is listed as criteria in goal statement. Does describe goal as met, partially met, or not met. If goal was partially met or not met, includes revision and new evaluation date/time.



Keywords:
  • Nursing, Care Plan

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