· Complete Patient Demographics

· Reproductive History

Information Related to Current Pregnancy

Information Related to Prior Pregnancies

· Newborn Information (if delivered)

· Current Medication

· Lab Work/Diagnostic Data

· Reflects the primary diagnosis

· Appropriate for patient scenario as well as priority level

· In acceptable NANDA format

· Includes all parts stem, R/T, AEB

· Appropriate for chosen diagnosis

· Includes objective & subjective historical support diagnosing data

·

· Include at least 2 outcomes for the diagnosis

· Specific to the patient diagnosis

· Contains the following 4 criteria:

measurable, attainable, realistic, and timed

· All criteria present for patient’s expected outcome

(Outcome 1)

____/ 2

(Outcome 2)

· Include at least 3 nursing interventions for each patient outcome

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· # of interventions is appropriate to help pt./ family meet their outcomes

____/ 3

(Interventions and Rationales for Outcome 2)

· Must have an evaluation statement written for each patient outcome

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

____/2

(Evaluation for Outcome 1)

____/ 2

(Evaluation for Outcome 2)