N233 NURSING PROCESS PAPER (NPP) RUBRIC Number

Student _______________________________ Date______________________

Instructions: Turn in a copy of the rubric with each NPP. Use Syllabus directions for writing paper. GRADE: _______________ Instructor: _____________________

SECTION	EXCELLENT (Exceeds standard- meets satisfactory criteria and adds the following )	SATISFACTORY (Meets standard- passing)	UNSATISFACTORY (Below standard)
NURSING ASSESMENT
	Lists complete DSMIV criteria for each diagnosis,	Lists DSM IV criteria for major diagnosis	Incomplete DSM IV criteria listed or incorrect criteria listed
	Assessment data including MSE are complete. Symptoms of diagnosis are assessed against diagnostic criteria	Assessment data and MSE are complete with areas of diagnostic criteria present.	MSE is incomplete with no clear focus to the assessment MSE is poorly organized with data in inappropriate categories
Laboratory/Diagnostic Tests	Implications for nursing actions relevant to lab results are noted.	All labs tested noted with results. Therapeutic drug levels are noted	Laboratory data is incomplete. With results that are abnormal not indicated. No laboratory data is reported.
Medications	All routine medications are listed with psychiatric indication, most commonly occurring side effects listed; patient teaching data included.	Routine medication is listed with classification from text identified. Most commonly occurring side effects, and patient teaching data included	Medication is incorrectly transcribed from the patient’s record. Data included is incorrect. Medications are listed with incomplete data
Laboratory Data	Implications for nursing actions are clearly identified. All labs tested noted with results. Therapeutic drug levels are noted	All labs tested noted with results. Therapeutic drug levels are noted	Laboratory data is incomplete. With results that are abnormal not indicated.
Developmental level	Accurately assesses and compares expected and actual developmental level	Correctly identifies expected developmental level Accurately assesses and compares expected and actual developmental level.	Incorrectly identifies expected developmental level
Sociocultural factors	Identifies nursing implications related to sociocultural factors. Accurately assesses and compares expected and actual developmental level.	Correctly identifies sociocultural factors present for individual patient. Correctly identifies expected developmental level	Sociocultural factors are not assessed. Fails to identify cultural factors present with assigned patient. Incorrectly identifies actual or expected developmental level
ANALYSIS
Actual/High Risk Nursing Diagnosis	Writes nursing diagnoses using NANDA terminology are clearly based on MSE and other assessment data. Diagnoses are accurately prioritized. Includes nursing diagnosis related to physical conditions when appropriate.	Writes nursing diagnoses utilize. NANDA terminology with “as evidenced by” and “related to” data included. Includes major defining characteristics for nursing diagnosis. Diagnoses are prioritized Relationship between MSE and other assessment data is clear	Nursing diagnosis does not include complete statement or is without a clear relationship to MSE and other assessment data. Incorrect nursing diagnoses are selected for specific patient problem.
PLANNING
Desired Short term Outcomes	Expected outcomes are derived from nursing diagnosis. They are measurable, behavioral, and specific and identify time for attainment	Expected outcomes are clearly derived from the nursing diagnosis. The outcomes are deficient in one category, i.e. specific, behavioral, or measurable	Expected outcomes are not clearly related to the nursing diagnosis. The outcomes are deficient in more than one category, i.e. specificity, behavioral, or measurable Expected outcomes have no clear relation to nursing diagnoses. .
Planned Nursing Interventions	Nursing interventions have a clear relationship to both nursing diagnoses and short-term outcomes. Nursing documentation is reflective of outcomes. Nursing diagnoses are referenced.	Planned nursing interventions are appropriate to nursing diagnosis and are referenced. The relationship to short term outcomes may be not be entirely clear but can be discerned.	Planned nursing interventions are not referenced. There is no clear relationship to short term outcomes. Planned nursing interventions are inappropriate for patient.
IMPLEMENTATION
Nursing Interventions	There is an explanation of why those not completed were not done.	Those that have been achieved are checked.	Fails to note those that have been achieved.
EVALUATION
Evaluation of response to medications	Medication efficacy is evaluated comprehensively. Those side effects experienced by patient noted and nursing response indicated.	Evaluation criteria for medications are listed. Most commonly occurring side effects listed. Identifies actual side effects present.	Evaluation criteria for medication efficacy are unclear. Some important commonly occurring side effects are not evaluated. Medication efficacy is not evaluated. Patient side effects are incompletely or inaccurately listed
Evaluation of individual outcomes	Outcome statements are evaluated. Reasons for outcomes that are not met are articulated	Evaluation of outcome statements is clear.	There is no indication that any nursing outcomes were achieved
Suggestions for revising plan.	Revision of plan recommended on the basis of evaluation.	Utilization of evaluation data to revise the plan of care is evident.	Evaluation of entire plan is incomplete with no utilization of evaluation data to revise care plan.

N241 NURSING PROCESS PAPER – GRADING RUBRIC

Student ____________________________ Instructor_____________________

A nursing process paper is usually submitted after each clinical week with the log. When two papers have met satisfactory criteria in each major area, then assessment worksheets from N240-241 syllabus (and your own adaptations) may be the primary approach to organization of essential data and serve as the foundation for provision of patient care.