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1. This criterion is linked to a Learning OutcomeHistory of present illness, pathophysiology of admitting diagnosis-HPI explains in detail with accurate and in-depth understanding of chief complaint and full explanation of pathophysiology for admitting diagnosis, supported by evidence-based citations.
2. Past medical, surgical, and social history, detailed with full explanation of pathophysiology for admitting diagnosis and for each diagnosis. Specific detail related to the client’s current history and symptoms and supported by evidence-based citations.
3.This criterion is linked to a Learning OutcomeSocioeconomic, Psychosocial, and Cultural Assessment & Psychosocial Concerns-Describes socioeconomic and cultural background in complete detail with references; identified 3 or more psychosocial concerns
4.Pertinent Diagnostic and Lab Tests-Clearly and accurately identifies pertinent laboratory tests with abnormal values and identifies trends related to a client’s disease process. Clearly and accurately describes the client’s diagnostic criteria which clearly supports the chief complaints and presenting signs/symptoms.
5.This criterion is linked to a Learning OutcomeMedical Management and Collaborative Plan-Clearly and accurately describes concerns related to management and offers extensive collaborative planning involving several members of the healthcare team.
6.This criterion is linked to a Learning OutcomePatient Education, Discharge Planning, Referrals and Consults-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. Lists appropriate collaborative issue/concern. Rationale and demonstrated proficient understanding of consults and interventions.
7.medication-Clearly and accurately identifies all components of the medication list, including mechanism of action, purpose, range, side effects, interactions, safe dosing ranges, including dosing calculation for min and max per weight of your patient, and nursing considerations relevant to the clien
8.Assessment & Review of the Systems-Documents full Head- to-Toe physical assessment – relevant to the patient/client as performed by the student. Utilizes an organized format and appropriate terms to describe both normal and abnormal assessment findings.
9.This criterion is linked to a Learning OutcomeRecognizing Cues-Identifies imperative cues taken from the environment, patient observation, medical record, other resources, time pressures, task complexity, and cultural considerations.
10.This criterion is linked to a Learning OutcomeAnalyzing Cues-Interprets cues from their existing knowledge base and nursing perspective, successfully evaluates cues in terms of relevancy, importance, and interrelationship among other cues, and organizes cues in clusters to develop a group of probable client needs/concerns and problems.
11.This criterion is linked to a Learning OutcomePrioritizes Hypotheses-Presents 4 probable client needs/concerns and problems generated and organizes them into an ordered list where the priority hypotheses are on the top. (ABCs, Maslow, safety, acute v chronic, unstable v stable, urgent v non- urgent)
12.Clinical Judgment-Clearly and accurately establishes 4 client outcome criteria that can be achieved with nursing assistance. The judgments clearly support the clinical decisions and plan of care. The judgments are easily measurable and realistic.
13.Generate Solutions & Rationale-Clearly and accurately identifies independent and collaborative solutions supported by scientific rationale and evidence-based practice. Solutions are always individualized, prioritized, organized, specific, and realistic. Nursing actions are always aimed at clinical judgments and directed at the stated health deviation based on nursing assessment.
14. tqke qction-Clearly and accurately sorts the actions (based on their evaluation in various dimensions) and carries out the action(s) to address the hypothesis/hypotheses with the highest priority first.
15.This criterion is linked to a Learning OutcomeOutcome/Evaluation/Reflection-Skillfully and independently identifies criteria for evaluation. Evaluates the effectiveness of actions taken against the clinical judgments; modifies, revises, and recommends alternative actions as needed.
16.This criterion is linked to a Learning OutcomeGeneral Organization-Accurate APA format, appropriate citations, and references, No spelling or grammar errors.
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