Clinical Judgment Plan

This criterion is linked to a Learning Outcome: History of present illness (HPI) and Admitting Diagnosis

3 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.2 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.

3 pts

This criterion is linked to a Learning Outcome: Pathophysiology of past medical/surgical/social histories

3 pts Proficient Includes 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 history and current signs/symptoms with evidence-based citations.2 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.

3 pts

This criterion is linked to a Learning Outcome: Social Determinants of Health

1 pt 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.0.75 ptsAcceptableAdequately 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.

1 pts

This criterion is linked to a Learning Outcome: Erikson’s Developmental Stages

1 ptsProficient1) Identifies and 2) defines correct stage 3) with examples of meeting/not meeting tasks 4) supported by evidence-based citations.0.75 ptsAcceptable1) Identifies and 2) defines correct stage 3) with vague examples of meeting/not meeting tasks 4) supported by evidence citations.

1 pts

This criterion is linked to a Learning Outcome: Teaching & Client Education

1 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.0.75 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,e and self-care activities. 5) Client education is supported by evidence-based practice.

1 pts

This criterion is linked to a Learning Outcome: Interprofessional Consults and Multidisciplinary Plan

1 ptsProficient1) 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.0.75 ptsAcceptable1) 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.

1 pts

This criterion is linked to a Learning Outcome: Discharge Planning

1 pts Proficient Clearly and accurately 1) describes issues/concerns related to discharge planning 2) with evidence-based rationales.0.75 ptsAcceptableAdequately 1) describes issues/concerns related to discharge planning 2) with evidence- based rationales.

1 pts

This criterion is linked to a Learning OutcomeLabs

1 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 client’s disease process 4) with evidence-based rationales.0.75 pts Acceptable Adpts Acceptable Adpts Acceptable Adequately pertinent laboratory tests with applicable indications, 2) addresses abnormal values, and 3) recognizes trends related to a client’s disease process 4) with evidence- based rationales.

1 pts

This criterion is linked to a Learning OutcomeDiagnostics/procedures

1 pts Proficient Clearly and accurately 1) describes the client’s diagnostic criteria and indications 2) with evidence- based rationales that clearly support the chief complaint and presenting signs/symptoms.0.75 pts Acceptable Adequately 1) describes the client’s diagnostic criteria and indications 2) with evidence-based rationales that adequately support the chief complaint and presenting signs/symptoms.

1 pts

This criterion is linked to a Learning OutcomeMedications

3 ptsProficientClearly 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 client’s current health condition, 2) with evidence-based citations.2 ptsAcceptableAdequately 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.

3 pts

This criterion is linked to a Learning Outcome Assessment & Review of Systems

5 ptsProficient1) 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.3.5 ptsAcceptable1) 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.

5 pts

This criterion is linked to a LearningOutcome: Recognitionn of Outcome: Recognition

4 pts Proficient Identifies cues taken from the environment, patient assessment/observation, medical record, other resources, time pressures, task complexity, and cultural considerations. Minimum of 15 cues required.3 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.

4 pts

This criterion is linked to a Learning Outcome: Analysis of cues (Analysis)

4 ptsProficient1) Links and clusters recognized cues to the client's clinical presentation. Accurately 2) establishes prioritized client needs based off the patient’s clinical presentation. Clearly and accurately clusters cues to establish probable patient needs, concerns, or problems.3 ptsAcceptable1) Links and clusters recognized cues to the client's clinical presentation. Adequately 2) establishes prioritized client needs based off the patient’s clinical presentation. Clearly and accurately clusters cues to establish probable patient needs, concerns, or problems.

4 pts

This criterion is linked to a Learning OutcomePrioritization of hOutcome: Prioritization

ptsProficient1) 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).3 ptsAcceptable1) 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).

4 pts

This criterion is linked to a Learning Outcome:Generationn of solutions (Planning)

6 pts Proficient Clearly and accurately 1) establishes one expected outcome to address each hypothesis that can be achieved with nursing assistance to ensure a client’s 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.4 pts Acceptable Adequately and apts Acceptable Adequatelys one expected outcome to address each hypothesis that can be achieved with nursing assistance to ensure a client’s 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.

6 pts

This criterion is linked to a Learning OutcomeTake actions (Implement Outcome: Take

sProficient1) 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 Erikson’s stages of development.3 ptsAcceptable1) 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 Erikson’s stages of development.

4 pts

This criterion is linked to a Learning OutcomeEvaluate Outcomes (EvaluaOutcome: EvaluateClearly

y 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.3 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.

4 pts

This criterion is linked to a Learning OutcomeGeneral Organization

1 ppt pt Outcome GGeneral andaccurate APA format. 2) Concisely appropriate citations and references. 3) No spelling or grammar errors.0.75 ptsAcceptable1) Adequate APA format. 2) Adequate appropriate citations and references. 3) Few spelling or grammar errors.

1 pts