Please follow the format below to complete this week’s Care Plan: Weekly Clinica

Please follow the format below to complete this week’s Care Plan:
Weekly Clinical Guided Reflection/Analysis
(Must show reflection and analysis in answers)
(Safety) How did you incorporate a standard precaution and infection control guideline? (Choose one you have not chosen before.)
Which National Patient Safety Goals did you use in your practice? (Choose one you have not chosen before.)
(Concept Care Map) What is the highest priority problem for your patient?  What is the rationale for this choice? Stroke
(Concept Care Map) What is the pathophysiology for the highest priority patient problem for each of your patients as it applies to the patient’s situation?
(Concept Care Map) Evaluate the patient goals for each of your patients (from your concept care map).
(Clinical Judgment) What did you learn about the concepts of the week from your patient(s) and experiences at clinical?
(Clinical Judgment) Think of one clinical decision you made which enhanced your patient’s care by addressing their cultural, developmental, and social characteristics.
(Clinical Judgment) Share an “ah-ha” moment of insight you experienced or witnessed today in clinical.
(Clinical Judgment) Share one thing you plan to do differently next week in clinical? 
(Patient Education) How did you assess the readiness of your patient and family member to learn?
Identify any learning barriers; possible resolution to barriers.
What content did you identify that you should teach your patient and/or family?
What teaching strategies did you use?
What teaching aides did you use?
(Patient Education) How did you verify their learning?
Did they learn the content?  If not, why not?
(Communication) Describe a therapeutic conversation you had with a patient or family member. Name the therapeutic communication technique you used? 
How did the person respond to your therapeutic communication technique?
Upon reflection, what would you have said differently?
Describe one communication barrier you observed.  How did it interfere with the communication? 
(Professionalism) Which standard of practice from the California Board of Nursing Rule did you implement? (Choose one you have not chosen before.)
How did you implement it?
(Leadership & Management) List interventions from your Concept-Care Map that you could only legally delegate to unlicensed personnel (UAP).
How did you advocate for your assigned patient(s)?
(Quality Improvement or Evidence-Based Practice) Identify and explain a quality improvement project at your hospital – or – identify an evidence-based practice used in the care of your patients.
(Concept Care Map) List all the interventions on your concept care map with cited scientific rationales.
Feedback from Instructor:
Instructor Signature:                                                                                                                                      Date:
Rubric
Care Plan Grading Rubric 100 points
Care Plan Grading Rubric 100 points
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeAssessment
18 to >17.0 pts
Expert
Includes all pertinent data related to nursing diagnosis and does not include data that is not related to nursing diagnosis.
17 to >15.0 pts
Proficient
Includes all pertinent data related to nursing diagnosis, but also includes data not related to nursing diagnosis.
15 to >13.5 pts
Apprentice
Does not include all pertinent data related to nursing diagnosis. May also include data that does not relate to nursing diagnosis.
13.5 to >0 pts
Novice
Assessment portion is incomplete.
18 pts
This criterion is linked to a Learning OutcomeDiagnosis
18 to >17.0 pts
Expert
Diagnosis is appropriate for patient and ordinal level, and diagnosis is NANDA approved. Diagnosis also includes all parts and information is listed in correct part of diagnosis.
17 to >15.0 pts
Proficient
Diagnosis is appropriate for patient and ordinal level, and diagnosis is NANDA approved, but does not include all parts or information is listed in wrong part of diagnosis.
15 to >13.5 pts
Apprentice
Diagnosis is not appropriate for patient and ordinal level (first diagnosis, second diagnosis, etc). May also not be NANDA and may not include all parts.
13.5 to >0 pts
Novice
Diagnosis portion is incomplete.
18 pts
This criterion is linked to a Learning OutcomePlanning
18 to >17.0 pts
Expert
Goal statement is patient or family oriented, and contains two measurable criteria and a target date or time.
17 to >15.0 pts
Proficient
Goal statement is patient or family oriented, and contains at least one measurable criteria or a target date/time.
15 to >13.5 pts
Apprentice
Goal statement is not patient or family oriented and may not have measurable criteria or a target date or time.
13.5 to >0 pts
Novice
Planning and goal setting portion is incomplete.
18 pts
This criterion is linked to a Learning OutcomeIntervention
18 to >17.0 pts
Expert
Interventions portion contains adequate number of interventions to help patient/family meet goal, and interventions are specific in action and frequency, labeled with “I” or “C” and are listed with referenced rationales.
17 to >15.0 pts
Proficient
Interventions portion contains adequate number of interventions to help patient/family meet goal, but interventions may not be specific, labeled or listed with rationales.
15 to >13.5 pts
Apprentice
Interventions portion does not include adequate number of interventions to help patient/family meet goal. Interventions may also not be specific, labeled or listed with rationales.
13.5 to >0 pts
Novice
Interventions portion is incomplete.
18 pts
This criterion is linked to a Learning OutcomeEvaluation
18 to >17.0 pts
Expert
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/or new evaluation date/time.
17 to >15.0 pts
Proficient
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.
15 to >13.5 pts
Apprentice
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.
13.5 to >0 pts
Novice
Evaluations portion is incomplete.
18 pts
This criterion is linked to a Learning OutcomeSpelling and Grammar
10 to >9.0 pts
Expert
No spelling &/or grammar mistakes.
9 to >8.0 pts
Proficient
Minimal spelling &/or grammar mistakes.
8 to >7.0 pts
Apprentice
Noticeable spelling & grammar mistakes.
7 to >0 pts
Novice
Unacceptable number of spelling and/or grammar mistakes.
10 pts
Total Points: 100
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