Medical Care Health Plan

Score

10

5

3

1

0

Assessment

All areas complete, specific and accurate or write N/A.

1-2 sections incomplete, information specific and accurate or write

N/A

3-4 sections incomplete information is generalized and accurate or N/A

Poor use of medical or nursing terminology, misspelling, incomplete sentences

Incomplete assessment or inaccurate data

Diagnosis

NANDA approved, highest priority, individualized and in PES format.

NANDA approved, highest priority, low individualization PES format

NANDA approved, lower priority, low individualization PES format

NANDA approved, low priority, not individualized PES format

Not NANDA approved, No priority, No individualization

Planning NIC/NOC

Individualized, attainable goal with stated time frame, interventions appropriate for diagnosis

Individualized, with attainable goal, 3 or more interventions appropriate for diagnosis

Individualized, with attainable goal, interventions appropriate for diagnosis, less than 3 appropriate interventions

Generalized with attainable goal and time frame. Interventions generalized

No goal provided, not appropriate for diagnosis, incomplete

Evaluation

Every intervention reviewed & evaluated. Revisions noted when appropriate

Every intervention reviewed; no revisions provided when appropriate

Interventions were not reviewed or revisions listed are not priority focused for patient. 

Limited review no revisions listed.

Evaluations do not relate to interventions

Medications

All medication cards are completed as the example. 

Medication cards complete but not relevant to specific patient.

 Not relevant to patient or 1-2 parts of the med card is missing

3-4 parts of the med card are missing

>4 parts missing

Score