Conduct a sensitive patient interview using therapeutic communication skills to complete a comprehensive health history of an assigned client in the clinical setting. Do not use patient identifiers i.e. name, DOB, employer, school, etc. 2)

Grading Criteria

10-9 points

8-7 points

6-5 points

4-3 points

2-1 points

Holistic Assessment

(10 points)

· Data is complete and accurate from chart review and patient, & family interview.

· Subjective data is collected through the use of sensitive inquiry.

· A rationale is provided for data that is not provided.

· Includes discussion of chronological events leading to hospitalization & progress since.

· Correctly identifies Erickson stage of Development with description of crisis resolution, supported by cues.

· Includes evidence of thorough body system assessment grouped in correct health pattern.

· Each functional area includes patient’s “normal” as well as changes occurring since current healthcare problem.

· Assessment is communicated factually and concisely with appropriate use of quotes

using correct terminology and spelling.

· Data is fairly complete and accurate from chart review and patient, & family interview.

· Subjective data is collected demonstrating presence of rapport.

· Includes discussion of chronological events leading to hospitalization.

· Correctly identifies Erickson stage of Development with description of crisis resolution.

· Includes evidence of some body system assessments grouped in correct health pattern, but some objective data not collected/performed.

· Each functional area includes only patient’s current state since healthcare problem.

· Assessment is clearly communicated with appropriate use of quotes.

· Generally uses correct terminology and spelling.

· Data is 80% incomplete from chart review and patient, & family interview.

· Subjective data is weak demonstrating lack of rapport.

· Briefly discusses events leading to hospitalization.

· Correctly identifies Erickson stage of Development, but fails to discuss crisis resolution.

· Includes evidence of basic body system assessments sometimes grouped in correct health pattern.  Some expected objective data not present.

· Data in functional areas varies between patient’s current state since healthcare problem and their normal state.

· Assessment is fairly communicated with no quotes.

· Errors in terminology and spelling present

· Incomplete data (70%) from chart review and patient & family interview.

· No rationale for omitted data.

· There is an absence of sensitive inquiry reflected in the absence of subjective data. 

· Omission or inaccurate identification of stage of development with little or no supporting data.

· Incomplete summarization of body system assessment.

· Areas are minimally addressed.

· Few descriptions of general assessment. 

· Lacks organization of data within correct health pattern.

· Includes opinion with no supporting data

· Does not meet criteria for professional submission with frequent errors in spelling and terminology.

· Data very incomplete, less than 70%

· Multiple health pattern areas have no data.

· Areas addressed have 1-2 lines of data.

· No evidence of own physical assessments present

· Data is poorly presented.

Summary

(10 points)

· Accurately summarizes all significant physiological & psychosocial findings.

· Includes strengths as well as weaknesses.

· Summary is logically organized and concisely tells the patient’s “story”.

· Summary leads to development of priority nursing diagnosis.

· Accurately summarizes most (80%) significant physiological & psychosocial findings, but misses some relevant cues. 

· Greater emphasis on weaknesses, but recognizes at least one strength.

· Summary is fairly well-organized.

· Contributes to identification of logical nursing diagnosis.

· Summarizes at least 70% of findings.

· Includes only physiological findings.

· Discusses only weaknesses.

· Summary is somewhat organized.

· Summary leads to identification of a nursing diagnosis, but not best choice.

· Several significant findings (50% or more) were not summarized.

· Discussion of identified strengths and weakness absent or inaccurate.

· Summary does not lead to accurate development of priority nursing needs.

· Fails to complete or summary very brief and excludes the majority of significant findings. 

· Focus on physical needs only. 

· No discussion of strengths. 

· Not useful in determining priority nursing needs.

Nursing Diagnosis

(10 points)

· Uses summary to correctly identify a priority problem from data presented.

· Diagnosis is a complete3-part statement (problem, etiology, & signs/symptoms) using correct NANDA terminology and format.

· Uses summary to correctly identify a significant problem from data presented, but not necessarily priority.

· Diagnosis is a complete3 or 2-part statement (problem, etiology, & signs/symptoms) with only minor errors in correct NANDA use.

· Inaccurately interprets data presented so problem identified is not appropriate for the client.

· Attempts to write diagnosis as a 3 or 2-part statement (problem, etiology, & signs/symptoms), bu multiple errors in correct NANDA use.

· The nursing diagnosis selected reflects minimal analysis or inaccurate interpretation of assessment information.

· Incompletely written, does not contain all of the elements of a 3 or 2-part NANDA diagnostic statement.

· Diagnosis chosen is not accurate and does not reflect a priority nursing need for the client based on the data. 

· Only the diagnostic label is presented with no attempt to complete the diagnostic statement.

Goals/ Evaluation

(10 points)

· Correctly writes two goals using the 5-part statement (subject, measureable verb, condition, criteria, time frame).

· One goal may be missing a single element.

· Goal is individualized, realistic for patient, and focuses on resolution of problem. 

· Each is written in the appropriate domain (cognitive, affective, or psychomotor) for problem resolution and includes a single outcome.

· The evaluation describes evaluative criteria appropriate for the domain that would determine if goal was or was not met. 

· Evaluates the goal as written.

· Both goals are missing one part of the 5-part statement (subject, measureable verb, condition, criteria, time frame). OR-

· Attempts to individualize goal but criteria may not be realistic for patient, or focus on resolution of problem.

· May not be written in the appropriate domain (cognitive, affective, or psychomotor) OR

· includes more than one outcome.

· Evaluation of one goal describes evaluative criteria appropriate for the domain that would determine if goal was or was not met, but 2^nd evaluation does not and may add criteria not evident in the goal.

· Both goals are missing more than one part of the 5-part statement (subject, measureable verb, condition, criteria, time frame). 

· Attempts to individualize goal but criteria may not be realistic for patient, or focus on resolution of problem.

· Not written in the appropriate domain (cognitive, affective, or psychomotor).

· Goals include more than one outcome.

· Neither evaluation correctly evaluates criteria as stated in the goal. 

· Evaluation is inconsistent with domain or adds criteria not evident in goal. 

· Goals are incomplete and do not have 5 parts of well-written goals or did not select measurable verb.

· Not realistic or individualized.

· Goal is not directed toward resolution of the problem.

· Does not state evaluative criteria that would be used to measure goal achievement.

· Evaluates the interventions rather than the goal, establishing criteria not evident in the goal.

· Includes outcomes as written in resources, with no attempt to write as a complete statement or individualize for the patient.

· Does not address evaluation or statements have no direct connection to goals as written. OR

· Unable to accurately evaluate because of errors in goals.

Interventions/Rationales

(10 points)

· Identifies three evidence-based, patient-centered nursing actions appropriate to achieve each goal. 

· Interventions are personalized, realistic, & written with sufficient detail to direct care of the health care team.

· Rationales are provided for each intervention.

· Rationales are comprehensive, theory-based, with citation of source. 

· Rationales clearly and succinctly identify why the intervention represents best practice & how it contributes to goal achievement.

· Identifies at least 2 evidence-based, patient-centered nursing actions for each goal, but other intervention does not meet criteria.

· Interventions are personalized but not written with sufficient detail to direct care of the health care team.

· Rationales are provided for each intervention.

· Rationales are comprehensive but not always theory-based. 

· Rationales identify why the intervention was selected and implies how it contributes to goal achievement.

· Some interventions are evidence-based and patient-centered, but the majority are not.

· Interventions are not personalized and lack sufficient detail to direct the care of the health care team.

· Rationales are provided for most interventions.

· Citations are provided on at least half.

· Many rationales lack substance with insufficient evidence of theory reflected. 

· Rationale does not clearly state how the intervention influences goal achievement. 

· The list of interventions is not complete, not patient-centered, or not based on current evidence. 

· Interventions are not related to the goal or are not nursing actions.

· Rationales are shallow, not based on scientific theory. 

· Does not provide rationales for all interventions.  

· Rationales lack citation of source. 

· Lists nursing actions verbatim from resources with no attempt to personalize or develops them without reference to resources.

· Rationales are restatements of interventions linked to goal without reference to theory stating how it exerts its effect.

· No citations present.

Reflection

(10 points)

· Strong evidence of reflective thought.

· Thoughtfully considers individualized health promotion opportunities based on patient history.

· Is clearly able to articulate how to effectively intervene to impact patient’s healthcare outcomes.

· Thoughtfully reflects on how providing care, interacting with the client, completing the assessment and plan of care contributed to professional growth.

· Thoughts are logically, & professionally articulated.

· Fair degree of reflection present.

· Considers health promotion opportunities appropriate for client’s diagnosis.

· Provides suggestion on how to intervene to impact patient’s healthcare outcomes.

· Lists what was learned by providing care, interacting with the client, completing the assessment and plan of care.

· Thoughts are clearly articulated and well-organized.

· Insufficient evidence of reflective thought. 

· Does not completely address all questions.

· Considers one health promotion opportunity for persons with this diagnosis.

· Vaguely states how one might intervene for an individual with this diagnosis.

· Briefly states what was learned by completing this assignment- doesn’t address all aspect of learning opportunities.

· Only brief statements per question with minimal evidence of reflective thought. 

· Addresses 2 of 3 questions. 

· Discusses care provided, but unable to relate to personal growth

· Addresses 1 of 3 questions. 

· The question addressed does not demonstrate evidence of the ability to self-reflect and thoughtfully consider the experiences of others.

· Does not state how assignment contributes to personal growth.