5 pts
10 pts
15 pts
25 pts
Includes subjective, objective and historical data that support actual or risk for nursing diagnosis.
Includes and prioritizes the most appropriate diagnoses for patient, including all appropriate parts (stem, [related to or R/T], and as evidenced by [AEB]) and are NANDA approved.
Includes patient and/or family goals most appropriate for the patient/family and each nursing diagnosis. Each goal should be measurable by at least two criteria and have a target date or time.
Includes interventions or nursing actions that directly relate to the patient's goal, that are specific in action and frequency, are labeled "I" for independent and "C" for collaborative, and include a referenced rationale with page number (if applicable). Number of interventions should be appropriate to help patient or family meet their goal.