5 pts
10 pts
15 pts
20 pts
Includes subjective, objective and historical data that support actual or risk for nursing diagnosis.
Relevant NANDA approved diagnosis written in proper form (includes stem, related to or R/T, and as evidenced by or AEB; or Risk for)
Includes patient or family goals based on the nursing diagnosis. Goals must be patient focused, realistic, and have clear measurable criteria with a target date/ time.
Nursing interventions or actions that directly relate to the etiology of the nursing diagnosis and the patient goal and desired outcome.
Uses APA style formatting for references.