Area to be scored

Scoring code

1. Health History by Review of Systems

a. Subjective data is accurate and complete

b. No blank areas (none or client denies problems annotated

where applicable)

2. Family Health History

a. Significant family medical data is accurate and complete

b. Familial relationship to client is clearly identified

c. Only pertinent medical history associated with 1st and 2nd

generation family members is annotated

3. Human Dimensions

a. All dimensions (A – G) are assessed.

b. Each dimension is assessed accurately and completely

4. Source and reliability of information is annotated

5. Client/Family Learning Needs Identified

6. Diagnostic Tests & Laboratory Data

a. Results of diagnostic tests / procedures are given

b. Interpretations of abnormal lab values are accurate

7. Physical Examination

a. Objective data is accurate and complete

8. Health-Illness Continuum

a. Based on previous subjective and objective data, the client is accurately positioned on the continuum

b. Rationale for placement on health-illness continuum is clear and accurate.

9. Risk Assessments are completed

10. Discharge Planning Needs are identified accurately

11. Nursing Diagnoses are accurate, appropriate, and based on

assessment data

a. Nursing Diagnosis are prioritized accurately

b. Nursing diagnoses include all 3 components (dx/rt/aeb)

11. Medications

a. Classification and sub-classification stated

b. Actions of medications are specific & purpose is stated

c. Nursing implications are appropriate and complete