clinical judgement plan

Proficient

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.

Acceptable

Explains HPI and ROS in some detail with adequate understanding of chief complaint. Evidence-based rationales adequately support the HPI and ROS.

Needs Improvement

Explains HPI and ROS in limited detail with limited understanding of chief complaint. Evidence-based rationales vaguely support the HPI and ROS or are not present.

Unsatisfactory

Fails to explain HPI and ROS with poor understanding of chief complaint. Evidence-based rationales do not support the HPI and ROS or are not present.

Proficient

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.

Acceptable

Adequately explains the pathophysiology for each admitting diagnosis and past medical/surgical history. Adequately associates specific details related to the client’s history and signs/symptoms with evidence-based citations.

Needs Improvement

Vaguely explains the pathophysiology for each admitting diagnosis and past medical/surgical history. Vaguely associates specific details related to the client’s history and signs/symptoms with limited to no evidence- based citations.

Unsatisfactory

Fails to provide pathophysiology of admitting diagnosis and past medical/surgical history. Does not associate specific details related to the client’s history and signs/symptoms with limited to no evidence- based citations.

Proficient

Clearly and accurately describes socioeconomic and psychosocial background in detail with evidence-based citations. Identifies at least 3 or more psychosocial concerns.

Acceptable

Adequately describes socioeconomic and psychosocial background in detail with evidence-based citations. Identifies at least 2 psychosocial concerns.

Needs Improvement

Vaguely describes socioeconomic and psychosocial background in detail with limited to no evidence-based citations. Identifies at least 1 psychosocial concern.

Unsatisfactory

Fails to describe socioeconomic and psychosocial background with limited to no evidence- based citations. Identified no psychosocial concerns.

Proficient

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.

Acceptable

Adequately identifies areas of instructional needs, learning preference and learning barriers. Provided some and adequate client education that aids in health promotion, health maintenance and self-care activities.

Needs Improvement

Vaguely identifies areas of instructional needs, learning preference and learning barriers. Provided minimal and vague client education that will aid in health promotion, health maintenance and self-care activities.

Unsatisfactory

Fails to identify areas of instructional needs, learning preference and learning barriers. Did not provide client education that will aid in health promotion, health maintenance and self-care activities.

Proficient

Lists at least 3 appropriate collaborative issues/concerns. Evidence- based rationales demonstrate clear and accurate understanding of consults and interventions.

Acceptable

Lists at least 2 appropriate collaborative issues/concerns. Evidence- based rationales demonstrate adequate understanding of consults and interventions.

Needs Improvement

Lists at least 1 appropriate collaborative issue/concern. Evidence-based rationales demonstrate vague understanding of consults and interventions or may be missing.

Unsatisfactory

Fails to list collaborative issues/concerns or lists issues/concerns that are inappropriate. Evidence- based rationales demonstrate unsatisfactory understanding of consults and interventions or may be missing.

Proficient

Clearly and accurately describes issues/concerns related to multidisciplinary discharge planning with evidence-based rationales.

Acceptable

Adequately describes issues/concerns related to multidisciplinary discharge planning with evidence- based rationales.

Needs Improvement

Vaguely describes issues/concerns related to multidisciplinary discharge planning with limited to no evidence-based rationales.

Unsatisfactory

Fails to describe issues/concerns related to multidisciplinary discharge planning with limited to no evidence-based rationales.

Proficient

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.

Acceptable

Adequately identifies pertinent laboratory tests with applicable indications, addresses abnormal values, and recognizes trends related to a client’s disease process with evidence- based rationales.

Needs Improvement

Vaguely identifies pertinent laboratory tests with applicable indications, addresses abnormal values, and recognizes trends related to a client’s disease process with limited to evidence-based rationales.

Unsatisfactory

Fails to identify pertinent laboratory tests with applicable indications, address abnormal values, or recognize trends related to a client’s disease process with limited to no evidence-based rationales.

Proficient

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.

Acceptable

Adequately describes the client’s diagnostic criteria and indications with evidence-based rationales that adequately support the chief complaint and presenting signs/symptoms.

Needs Improvement

Vaguely describes the client’s diagnostic criteria and indications with limited to no rationales which vaguely support the identified chief complaint and presenting signs/symptoms.

Unsatisfactory

Fails to describe the client’s diagnostic criteria and indications with limited to no rationales and does not support the identified chief complaint and presenting signs/symptoms.

Proficient

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.

Acceptable

Adequately identifies some 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.

Needs Improvement

Vaguely identifies few components of the medication list with limited to no 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.

Unsatisfactory

Fails to identify all components of the medication list with limited to no 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.

Proficient

Identifies at least 4 or more imperative assessment cues. All cues are relevant. Evidence-based citations clearly and accurately support the cues.

Acceptable

Identifies at least 2 imperative assessment cues. Some cues are relevant. Evidence-based citations adequately support the cues.

Needs Improvement

Identifies at least 1 imperative assessment cue. Few cues are relevant. Evidence-based citations vaguely support the cues or are missing.

Unsatisfactory

Fails to identify imperative assessment cues. Cues are not relevant. Evidence- based citations are limited or are missing.

Proficient

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.

Acceptable

The analysis of cues adequately supports the prioritized client needs and plan of care. Adequately links cues to a patient’s clinical presentation in establishing probable patient needs, concerns, or problems. Some cues are analyzed with evidence- based citations.

Needs Improvement

The analysis of cues vaguely supports the prioritized client needs and plan of care. Vaguely links cues to a patient’s clinical presentation in establishing probable patient needs, concerns, or problems. Few cues are analyzed with limited to no evidence-based citations.

Unsatisfactory

Fails to analyze cues or does not support the prioritized client needs and plan of care. Fails to link cues to a patient’s clinical presentation in establishing probable patient needs, concerns, or problems. No cues are analyzed or do not have evidenced-based citations.

Proficient

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.

Acceptable

Identifies at least 4 nursing clinical judgments that are adequate and prioritized with sufficient etiology and data to support rationale. The clinical decision is adequate and presents correlation from the recognized cues based on priority-setting frameworks.

Needs Improvement

Identifies less than or equal to 4 nursing clinical judgments that are vague and not prioritized with insufficient etiology and data to support rationale. The clinical decision is vague and may or may not have correlation from the recognized cues based on priority-setting frameworks or is missing.

Unsatisfactory

Fails to identify nursing clinical judgments or is not prioritized with insufficient etiology and data to support rationale. Fails to identify clinical decisions with no correlation from the recognized cues based on priority-setting frameworks.

Proficient

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.

Acceptable

Adequately establishes client’s goal/outcome criteria that can be achieved with nursing assistance. The goal/outcomes adequately support the clinical judgments and plan of care. Some goals/outcomes are time-limited to the date/time of care and are specific, measurable, attainable, and relevant.

Needs Improvement

Vaguely establishes client’s goal/outcome criteria that may be achieved with nursing assistance. The goal/outcomes vaguely support the clinical decisions and plan of care. Few goals/outcomes are time- limited to the date/time of care and may or may not be specific, measurable, attainable, and relevant.

Unsatisfactory

Fails to establish client’s goal/outcome criteria that may be achieved with nursing assistance. The goal/outcome does not support the clinical decisions and plan of care. Goals/outcomes are not time-limited to the date/time of care and are not specific, measurable, attainable, or relevant.

Proficient

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.

Acceptable

Adequately identifies at least 14 to 16 actions that are independent nursing interventions supported by scientific rationale and evidence-based practice. Some interventions are individualized, prioritized, specific, and with timed frequencies. Nursing actions are adequately aimed at the client’s goals and sometimes directed at the stated health deviation based on the nursing assessment and Erikson’s stages of development.

Needs Improvement

Vaguely identifies at least 12 to 14 actions that are independent nursing interventions that may or may not be supported by scientific rationale and evidence-based practice. Few interventions are individualized, prioritized, specific, and may or may not notate timed frequencies. Nursing actions are vaguely aimed at the client’s goals and may or may not be directed at the stated health deviation based on the nursing assessment and Erikson’s stages of development.

Unsatisfactory

Fails to identify at least 12 actions that are independent nursing interventions supported by scientific rationale and evidence-based practice. Interventions are not individualized, prioritized, specific, or do not have timed frequencies. Nursing actions are not aimed at the client’s goals and are not directed at the stated health deviation based on the nursing assessment and Erikson’s stages of development.

Proficient

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.

Acceptable

Adequately identifies criteria for evaluation, effectiveness of interventions, and measurement of goal completion. Evaluation is adequately linked to the generated solutions and overall plan of care. Modifies, revises, and recommends alternative intervention(s) with evidence-based citations as applicable.

Needs Improvement

Vaguely identifies criteria for evaluation, effectiveness of interventions, and measurement of goal completion. Evaluation is vaguely linked with generated solutions and overall plan of care. May or may not modify, revise, or recommend alternative intervention(s) with limited to no evidence-based citations as applicable.

Unsatisfactory

Fails to identify criteria for evaluation, effectiveness of interventions, and measurement of goal completion. Evaluation is not linked with generated solutions and overall plan of care. Does not modify, revise, or recommend alternative intervention(s) with limited to no evidence- based citations as applicable.

Proficient

Clear and accurate APA format. Concisely appropriate citations and references. No spelling or grammar errors.

Acceptable

Adequate APA format. Adequate appropriate citations and references, Few spelling or grammar errors.

Needs Improvement

Inadequate APA format. Inappropriate citations and references. Some spelling or grammar errors.

Unsatisfactory

Fails to utilize APA format. No appropriate citations and references. Many spelling or grammar errors.