RUBRIC
History of present illness (HPI) and comprehensive clinical examination/review of systems (ROS): Explains HPI and ROS in detail with clear and accurate understanding of chief complaint. Evidence-based rationales clearly and accurately support the HPI and ROS.
Pathophysiology of admitting diagnosis and past medical/surgical histories: Clearly and accurately explains the pathophysiology for each admitting diagnosis and past medical/surgical history. Clearly and accurately associates specific details related to the client’s history and signs/symptoms with evidence-based citations.
Socioeconomic/psychosocial assessment: Clearly and accurately describes socioeconomic and psychosocial background in detail with evidence-based citations. Identifies at least 3 or more psychosocial concerns.
Teaching assessment & client education: Clearly and accurately identifies areas of instructional needs, learning preference, and learning barriers. Provided clear and concise client education that will aid in health promotion, health maintenance and self-care activities.
Interprofessional consults and collaborative plan: Lists at least 3 appropriate collaborative issues/concerns. Evidence- based rationales demonstrate clear and accurate understanding of consults and interventions.
Multidisciplinary client outcome and discharge planning/referrals: Clearly and accurately describes issues/concerns related to multidisciplinary discharge planning with evidence-based rationales.
Labs: Clearly and accurately identifies pertinent laboratory tests with applicable indications, addresses abnormal values, and recognizes trends related to a client’s disease process with evidence- based rationales.
Diagnostics/procedures: Clearly and accurately describes the client’s diagnostic criteria and indications with evidence- based rationales that clearly support the chief complaint and presenting signs/symptoms.
Medications: Clearly and accurately identifies all components of the medication list with evidence-based citations, including name, class, route, dose, frequency, mechanism of action, applicable indication(s), side and adverse effects, interactions, and nursing considerations relevant to the client.
Recognition of cues: Identifies at least 4 or more imperative assessment cues. All cues are relevant. Evidence-based citations clearly and accurately support the cues.
Analysis of cues: The analysis of cues clearly and accurately supports the prioritized client needs and plan of care. Clearly and accurately links cues to a patient’s clinical presentation in establishing probable patient needs, concerns, or problems. All cues are analyzed with evidence- based citations.
Prioritization of hypotheses (clinical judgments): Identifies at least 4 nursing clinical judgements that are clear, accurate, and prioritized with clear etiology and data to support rationale. The clinical decision is clear, accurate, and presents correlation from the recognized cues based on priority-setting frameworks.
Generation of solutions (S.M.A.R.T goals/outcomes): Clearly and accurately establishes client’s goal/outcome criteria that can be achieved with nursing assistance. The goal/outcomes clearly and accurately support the clinical judgments and plan of care. All goals/outcomes are time-limited to the date/time of care and are specific, measurable, attainable, and relevant.
Implementation of actions (interventions): Clearly and accurately identifies at least 16 actions that are independent nursing interventions supported by scientific rationale and evidence-based practice. All interventions are individualized, prioritized, specific, and with timed frequencies. Nursing actions are always aimed at the client’s goals and directed at the stated health deviation based on the nursing assessment and Erikson’s stages of development
Evaluation: Clearly and accurately identifies criteria for evaluation, effectiveness of interventions, and measurement of goal completion. Evaluation is clearly and accurately linked to the generated solutions and overall plan of care. Modifies, revises, and recommends alternative intervention(s) with evidence-based citations as applicable.
General Organization: Clear and accurate APA format. Concisely appropriate citations and references. No spelling or grammar errors.
RUBRIC History of present illness (HPI) and comprehensive clinical examination/r
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