4 pts
3 pts
2 pts
1 pts
Include subjective/objective data; lab data if applicable
Related to... As evidenced by...
One long term and one short term
3 implementations for each area of assessment
Were goals met? Provide evidence. If unmet, describe how interventions and/or goals could be changed
List of all medications the patient is currently taking including IV medications with Drug Name Classification Use Action Dose Route Side Effects Nursing implications