clinical gagement plan CJP

tCriteriaRatingsPtsHistory of present illness (HPI) and Admitting Diagnosis

1 pts

Proficient

Explains 1) HPI and 2) admitting pathophysiology in detail with clear and accurate and in-depth understanding of chief complaint. 3) Evidence-based rationales clearly and accurately support the HPI.

0.75 pts

Acceptable

Explains 1) HPI and 2) admitting pathophysiology in some detail with adequate understanding of chief complaint. 3) Evidence-based rationales adequately support the HPI.

0.5 pts

Needs Improvement

Explains 1) HPI and 2) admitting pathophysiology in limited detail with limited understanding of chief complaint. 3) Evidence-based rationales vaguely support the HPI or are not present.

0 pts

Unsatisfactory

Fails to explain 1) HPI or 2) admitting pathophysiology with poor understanding of chief complaint. 3) Evidence-based rationales do not support the HPI or are not present.

/ 1 pts

Pathophysiology of past medical/surgical/social histories

1 pts

Proficient

Includes 1) all past medical, surgical, and social history detailed with 2) full explanation of pathophysiology for each diagnosis. 3) Thoroughly describes potential complications for each diagnosis and the indications for surgery. 4) Clearly and accurately relates the client’s past history and current signs/symptoms with evidence-based citations.

0.75 pts

Acceptable

Includes 1) most past medical, surgical, and social history detailed with 2) partial explanation of pathophysiology for each diagnosis. 3) Adequately describes potential complications for each diagnosis and the indications for surgery. 4) Adequately associates specific details related to the client’s history and signs/symptoms with evidence-based citations.

0.5 pts

Needs Improvement

Includes 1) some past medical, surgical, and social history detailed with 2) minimal explanation of pathophysiology for each diagnosis. 3) Vaguely describes potential complications for each diagnosis and the indications for surgery. 4) Vaguely associates specific details related to the client’s history and signs/symptoms with limited to no evidence- based citations.

0 pts

Unsatisfactory

No 1) past medical, surgical, or social history or given without 2) explanation or pathophysiology. 3) Does not describe potential complications for each diagnosis or the indications for surgery. 4) Does not associate specific details related to the client’s history and signs/symptoms with limited to no evidence- based citations.

/ 1 pts

Social Determinants of Health

0.5 pts

Proficient

Clearly and accurately 1) describes socioeconomic and psychosocial background in detail 2) with evidence-based citations to support social determinants of health. 3) Identifies at least 3 or more psychosocial concerns with interventions/ recommendations.

0.35 pts

Acceptable

Adequately 1) describes socioeconomic and psychosocial background in detail 2) with evidence-based citations to support social determinants of health. 3) Identifies at least 2 psychosocial concerns with interventions/ recommendations.

0.2 pts

Needs Improvement

Vaguely 1) describes socioeconomic and psychosocial background in detail 2) with limited to no evidence-based citations to support social determinants of health. 3) Identifies at least 1 psychosocial concern with interventions/recommendations.

0 pts

Unsatisfactory

Fails to 1) describe socioeconomic and psychosocial background 2) with limited to no evidence- based citations or social determinants of health. 3) Identifies no psychosocial concerns or interventions/ recommendations.

/ 0.5 pts

Eriksons Developmental Stages

0.5 pts

Proficient

1) Identifies and 2) defines correct stage 3) with examples of meeting/not meeting tasks 4) supported by evidenced-based citations.

0.35 pts

Acceptable

1) Identifies and 2) defines correct stage 3) with vague examples of meeting/not meeting tasks 4) supported by evidenced citations.

0.2 pts

Needs Improvement

1) Identifies correct stage 2) without adequate definition and 3) without examples of meeting or not meeting tasks. 4) No citations

0 pts

Unsatisfactory

1) Identifies incorrect stage 2) without definition or 3) without examples of meeting/not meeting tasks 4) without citations.

/ 0.5 pts

Teaching Assessment & Client Education

0.5 pts

Proficient

Clearly and accurately 1) identifies areas of instructional needs, 2) learning preference, and 3) learning barriers. 4) Provides clear and concise client education related to their condition that will aid in health promotion, health maintenance and self-care activities. 5) Client education is supported by evidence-based practice.

0.35 pts

Acceptable

Adequately 1) identifies areas of instructional needs, 2) learning preference and 3) learning barriers. 4) Provides adequate client education related to their condition that aids in health promotion, health maintenance and self-care activities. 5) Client education is supported by evidence-based practice.

0.2 pts

Needs Improvement

Vaguely 1) identifies areas of instructional needs, 2) learning preference and 3) learning barriers. 4) Provides minimal and vague client education that will aid in health promotion, health maintenance and self-care activities. 5) Client education is supported by evidence-based practice.

0 pts

Unsatisfactory

Fails to 1) identify areas of instructional needs, 2) learning preference and 3) learning barriers. 4) Does not provide client education that will aid in health promotion, health maintenance and self-care activities. 5) Client education is not supported by evidence-based practice.

/ 0.5 pts

Interprofessional Consults and Multidisciplinary Plan

0.5 pts

Proficient

1) Lists at least 3 appropriate collaborative issues/concerns. 2) Identifies 3 interdisciplinary consults to support patient well-being. 3) Evidence- based rationales demonstrate clear and accurate understanding of consults and interventions.

0.35 pts

Acceptable

1) Lists at least 2 appropriate collaborative issues/concerns. 2) Identifies 2 interdisciplinary consults to support patient well-being. 3) Evidence- based rationales demonstrate adequate understanding of consults and interventions.

0.2 pts

Needs Improvement

1) Lists at least 1 appropriate collaborative issue/concern. 2) Identifies 1 interdisciplinary consult to support patient well-being. 3) Evidence-based rationales demonstrate vague understanding of consults and interventions or may be missing.

0 pts

Unsatisfactory

1) Fails to list collaborative issues/concerns or lists issues/concerns that are inappropriate. 2) No interdisciplinary consults identified. 3) Evidence- based rationales demonstrate unsatisfactory understanding of consults and interventions or may be missing.

/ 0.5 pts

Discharge Planning

0.5 pts

Proficient

Clearly and accurately 1) describes issues/concerns related to discharge planning 2) with evidence-based rationales.

0.35 pts

Acceptable

Adequately 1) describes issues/concerns related to discharge planning 2) with evidence- based rationales.

0.2 pts

Needs Improvement

Vaguely 1) describes issues/concerns related to discharge planning 2) with limited to no evidence-based rationales.

0 pts

Unsatisfactory

Fails to 1) describe issues/concerns related to discharge planning 2) with limited to no evidence-based rationales.

/ 0.5 pts

Labs

0.5 pts

Proficient

Clearly and accurately 1) identifies admission and current pertinent laboratory tests with applicable indications, 2) addresses abnormal values, and 3) recognizes trends related to a clients disease process 4) with evidence-based rationales.

0.35 pts

Acceptable

Adequately 1) identifies pertinent laboratory tests with applicable indications, 2) addresses abnormal values, and 3) recognizes trends related to a clients disease process 4) with evidence- based rationales.

0.2 pts

Needs Improvement

Vaguely 1) identifies pertinent laboratory tests with applicable indications, 2) addresses abnormal values, and 3) recognizes trends related to a clients disease process 4) with limited to evidence-based rationales.

0 pts

Unsatisfactory

Fails to 1) identify pertinent laboratory tests with applicable indications, 2) address abnormal values, or 3) recognize trends related to a clients disease process 5) with limited to no evidence-based rationales.

/ 0.5 pts

Diagnostics/procedures

0.5 pts

Proficient

Clearly and accurately 1) describes the clients diagnostic criteria and indications 2) with evidence- based rationales that clearly support the chief complaint and presenting signs/symptoms.

0.35 pts

Acceptable

Adequately 1) describes the clients diagnostic criteria and indications 2) with evidence-based rationales that adequately support the chief complaint and presenting signs/symptoms.

0.2 pts

Needs Improvement

Vaguely 1) describes the clients diagnostic criteria and indications 2) with limited to no rationales which vaguely support the identified chief complaint and presenting signs/symptoms.

0 pts

Unsatisfactory

Fails to 1) describe the clients diagnostic criteria and indications 2) with limited to no rationales and does not support the identified chief complaint and presenting signs/symptoms.

/ 0.5 pts

Medications

1 pts

Proficient

Clearly and accurately 1) identifies all components of the medication list, including name, class, route, dose, frequency, mechanism of action, applicable indication(s), side and adverse effects, interactions, and nursing considerations relevant to the clients current health condition, 2) with evidence-based citations.

0.75 pts

Acceptable

Adequately 1) identifies some components of the medication list, including name, class, route, dose, frequency, mechanism of action, applicable indication(s), side and adverse effects, interactions, and nursing considerations relevant to the client, 2) with evidence-based citations.

0.5 pts

Needs Improvement

Vaguely 1) identifies few components of the medication list, including name, class, route, dose, frequency, mechanism of action, applicable indication(s), side and adverse effects, interactions, and nursing considerations relevant to the client, 2) with limited to no evidence-based citations.

0 pts

Unsatisfactory

Fails to 1) identify all components of the medication list, including name, class, route, dose, frequency, mechanism of action, applicable indication(s), side and adverse effects, interactions, and nursing considerations relevant to the client, 2) with limited to no evidence-based citations.

/ 1 pts

Assessment & Review of Systems

1 pts

Proficient

1) Documents thorough Head-to-Toe physical assessment with relevant information to the patient/client as performed by the student. 2) Utilizes an organized format and appropriate terms to describe both normal and abnormal assessment findings.

0.75 pts

Acceptable

1) Documents Head-to-Toe physical assessment with more than 75% relevant information to the patient/client as performed by the student. 2) Utilizes an organized format and appropriate terms to describe both normal and abnormal assessment findings.

0.5 pts

Needs Improvement

1) Documents full Head-to-Toe physical assessment with approx. 50% -75% relevant information to the patient/client as performed by the student. 2) Format may be moderately disorganized with mostly appropriate terms to describe both normal and abnormal assessment findings.

0 pts

Unsatisfactory

1) Documents full Head-to-Toe physical assessment with less than 50% relevant information to the patient/client missing information – as performed by the student. 2) Format is mostly disorganized and may be lacking appropriate terms to describe both normal and abnormal assessment findings.

/ 1 pts

Recognition of cues (Assessment)

1 pts

Proficient

Identifies all imperative cues taken from the environment, patient assessment/observation, medical record, other resources, time pressures, task complexity, and cultural considerations. Minimum of 15 cues required.

0.75 pts

Acceptable

Identifies most imperative assessment cues. Some cues are relevant. cues taken from the environment, patient assessment/observation, medical record, other resources, time pressures, task complexity, and cultural considerations. Less than 15 cues.

0.5 pts

Needs Improvement

Identifies some assessment cues. Few cues are relevant. cues taken from the environment, patient assessment/observation, medical record, other resources, time pressures, task complexity, and cultural considerations. Less than 10 cues.

0 pts

Unsatisfactory

Fails to identify imperative assessment cues. Cues are not relevant. Less than 5 cues.

/ 1 pts

Analysis of cues (Analysis)

1 pts

Proficient

1) Links and clusters recognized cues to the client’s clinical presentation. Accurately 2) establishes prioritized client needs based off the patients clinical presentation. Clearly and accurately clusters cues to establish probable patient needs, concerns, or problems.

0.75 pts

Acceptable

1) Links and clusters recognized cues to the client’s clinical presentation. Adequately 2) establishes prioritized client needs based off the patients clinical presentation. Clearly and accurately clusters cues to establish probable patient needs, concerns, or problems.

0.5 pts

Needs Improvement

Does not 1) link and cluster recognized cues to the client’s clinical presentation. Vaguely 2) establishes prioritized client needs based off the patients clinical presentation. Clearly and accurately clusters cues to establish probable patient needs, concerns, or problems.

0 pts

Unsatisfactory

Fails to 1) analyze cues or does not support the prioritized client needs and plan of care. 2) Fails to link and cluster cues to a patients clinical presentation in establishing probable patient needs, concerns, or problems.

/ 1 pts

Prioritization of hypotheses (Analyze)

1 pts

Proficient

1) Establishes 4 priorities of care based on the client’s health problems (i.e., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic tests, lab values). 2) The clinical decision is clear, accurate, and presents correlation from the recognized cues. 3) Identifies the framework used to identify priority order (ABCs, Maslow, safety, acute v chronic, unstable v stable, urgent v non-urgent).

0.75 pts

Acceptable

1) Establishes 3 priorities of care based on the client’s health problems (i.e., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic tests, lab values). 2) The clinical decision is mostly clear, accurate, and presents correlation from the recognized cues. 3) Identifies the framework used to identify priority order (ABCs, Maslow, safety, acute v chronic, unstable v stable, urgent v non-urgent).

0.5 pts

Needs Improvement

1) Establishes 2 or less priorities of care based on the client’s health problems (i.e., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic tests, lab values). 2) The clinical decision is vague or incorrect, and presents little correlation from the recognized cues. 3) Identifies the framework used to identify priority order (ABCs, Maslow, safety, acute v chronic, unstable v stable, urgent v non-urgent).

0 pts

Unsatisfactory

1) Fails to establish priorities of care based on the client’s health problems (i.e., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic tests, lab values). 2) Fails to identify clinical decisions with no correlation from the recognized cues. 3) Does not identify the framework used to identify priority order (ABCs, Maslow, safety, acute v chronic, unstable v stable, urgent v non-urgent).

/ 1 pts

Generation of solutions (Planning)

2 pts

Proficient

Clearly and accurately 1) establishes one expected outcome to address each hypothesis that can be achieved with nursing assistance to ensure a clients needs are met. Outcomes are specific, measurable, realistically attainable, and appropriately timed. 2) Identifies 4 solutions for each outcome supported by evidence-based practice. Clearly and accurately identifies at least 16 solutions that are independent nursing interventions supported by scientific rationale and evidence-based practice.

1.5 pts

Acceptable

Adequately and accurately 1) establishes one expected outcome to address each hypothesis that can be achieved with nursing assistance to ensure a clients needs are met. Outcomes are mostly specific, measurable, realistically attainable, and appropriately timed. 2) Identifies 3 solutions for each outcome supported by evidence-based practice. Clearly and accurately identifies at least 12 solutions that are independent nursing interventions supported by scientific rationale and evidence-based practice.

1 pts

Needs Improvement

Vaguely and accurately 1) establishes one expected outcome to address each hypothesis that can be achieved with nursing assistance to ensure a clients needs are met. Outcomes are somewhat specific, measurable, realistically attainable, and appropriately timed. 2) Identifies 2 solutions for each outcome supported by evidence-based practice. Clearly and accurately identifies at least 8 solutions that are independent nursing interventions supported by scientific rationale and evidence-based practice.

0 pts

Unsatisfactory

Fails to 1) establish one expected outcome to address each hypothesis that can be achieved with nursing assistance to ensure a clients needs are met. Outcomes are not specific, measurable, realistically attainable, and appropriately timed. 2) Identifies no solutions for each outcome supported by evidence-based practice. Clearly and accurately identifies at least 4 solutions that are independent nursing interventions supported by scientific rationale and evidence-based practice.

/ 2 pts

Take actions (Implementation)

1 pts

Proficient

1) Implements appropriate interventions in priority order based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client’s health. 2) Nursing actions are always aimed at the expected outcomes and directed at the stated health deviation based on the nursing assessment and Eriksons stages of development.

0.75 pts

Acceptable

1) Implements adequate interventions in priority order based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client’s health. 2) Nursing actions are aimed at the expected outcomes and directed at the stated health deviation based on the nursing assessment and Eriksons stages of development.

0.5 pts

Needs Improvement

1) Implements vague interventions that are not prioritized based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client’s health. 2) Nursing actions are vaguely aimed at the expected outcomes and are directed at the stated health deviation based on the nursing assessment and Eriksons stages of development.

0 pts

Unsatisfactory

Does not 1) implement appropriate interventions in priority order based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client’s health. 2) Nursing actions do not address expected outcomes and are not directed at the stated health deviation based on the nursing assessment and Eriksons stages of development.

/ 1 pts

Evaluate Outcomes (Evaluation)

1 pts

Proficient

Clearly and accurately 1) identifies criteria for evaluation, effectiveness of interventions, and measurement of goal completion. 2) Evaluation is clearly and accurately linked to the generated solutions and overall plan of care. 3) Modifies, revises, and recommends alternative solutions with evidence-based citations as applicable.

0.75 pts

Acceptable

Adequately 1) identifies criteria for evaluation, effectiveness of interventions, and measurement of goal completion. 2) Evaluation is adequately linked to the generated solutions and overall plan of care. 3) Modifies, revises, and recommends alternative solutions with evidence-based citations as applicable.

0.5 pts

Needs Improvement

Vaguely 1) identifies criteria for evaluation, effectiveness of interventions, and measurement of goal completion. 2) Evaluation is vaguely linked with generated solutions and overall plan of care. 3) May or may not modify, revise, or recommend alternative solutions with limited to no evidence-based citations as applicable.

0 pts

Unsatisfactory

Fails to 1) identify criteria for evaluation, effectiveness of interventions, and measurement of goal completion. 2) Evaluation is not linked with generated solutions and overall plan of care. 3) Does not modify, revise, or recommend alternative solutions with limited to no evidence- based citations as applicable.

/ 1 pts

General Organization

0.5 pts

Proficient

1) Clear and accurate APA format. 2) Concisely appropriate citations and references. 3) No spelling or grammar errors.

0.35 pts

Acceptable

1) Adequate APA format. 2) Adequate appropriate citations and references. 3) Few spelling or grammar errors.

0.2 pts

Needs Improvement

1) Inadequate APA format. 2) Inappropriate citations and references. 3) Some spelling or grammar errors.

0 pts

Unsatisfactory

1) Fails to utilize APA format. 2) No appropriate citations and references. 3) Many spelling or grammar errors.

/ 0.5 pts

Total Points: 0

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