EDS Clinical Judgment Plan – PEDS Clinical Judgment Plan

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EDS Clinical Judgment Plan
PEDS Clinical Judgment Plan
Criteria Ratings Pts
This criterion is linked to a Learning Outcome History of present illness, pathophysiology of admitting diagnosis
8 pts
Proficient
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.
6 pts
Acceptable
HPI explains in some detail with moderate understanding of chief complaint and explanation of pathophysiology for admitting diagnosis, or no support from evidence-based citations.
4 pts
Needs Improvement
HPI explains in limited detail with insufficient understanding of chief complaint and limited explanation of pathophysiology for admitting diagnosis, or support from evidence- based citations.
2 pts
Unsatisfactory
HPI details limited with poor understanding of chief complaint and no explanation of pathophysiology for admitting diagnosis, and no evidence-based citations to support.
8 pts
This criterion is linked to a Learning OutcomePast Medical, Surgical History and Pathophysiology, Social History
5 pts
Proficient
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.
4 pts
Acceptable
Past medical, surgical, and social history given with partial explanation of identified admitting diagnosis and preexisting medical diagnoses, intermittent details related to the client’s history and symptoms, or not completely supported by evidence-based citations.
2.5 pts
Needs Improvement
Past medical, surgical, and social history given with minimal explanation of identified admitting diagnosis and preexisting medical diagnoses; few to no details related to the client’s history and symptoms; or not supported by evidence-based citations.
1 pts
Unsatisfactory
No past medical, surgical, and social history given or given without explanation; no admitting diagnosis and or pre-existing medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without evidence.
5 pts
This criterion is linked to a Learning OutcomeSocioeconomic, Psychosocial, and Cultural Assessment & Psychosocial Concerns
6 pts
Proficient
Describes socioeconomic and cultural background in complete detail with references; identified 3 or more psychosocial concerns.
4.5 pts
Acceptable
Describes socioeconomic and cultural background with limited detail without references; identified 1-2 psychosocial concern.
3 pts
Needs Improvement
Describes socioeconomic and cultural background in vague detail without references; identified 1 psychosocial concern.

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1 pts
Unsatisfactory
Describes socioeconomic and cultural background with no detail without references; identified no psychosocial concerns.
6 pts
This criterion is linked to a Learning OutcomeErickson’s Developmental Stages
4 pts
Proficient
Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidenced based citations.
3 pts
Acceptable
Identifies and defines correct stage with vague examples of meeting/not meeting tasks supported by evidenced citations.
2 pts
Needs Improvement
Identifies correct stage without adequate definition and without examples of meeting or not meeting tasks. No citations.
1 pts
Unsatisfactory
Identifies incorrect stage without definition or example of meeting/not meeting tasks without citations.
4 pts
This criterion is linked to a Learning OutcomePertinent Diagnostic and Lab Tests
6 pts
Proficient
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.
4 pts
Acceptable
Adequately identifies pertinent laboratory tests with abnormal values and identifies trends related to the client’s disease process. Adequately describes the client’s diagnostic criteria which adequately supports the identified chief complaint and presenting signs/symptoms.
2 pts
Needs Improvement
Vaguely identifies pertinent laboratory tests with abnormal values and identifies trends related to the client’s disease process. Vaguely describes the client’s diagnostic criteria which vaguely supports the identified chief complaint and presenting signs/symptoms.
1 pts
Unsatisfactory
Fails to identify pertinent laboratory tests with abnormal values and identify trends related to the client’s disease process. Lacks description of the client’s diagnostic criteria that does not support the identified chief complaint and presenting signs/symptoms.
6 pts
This criterion is linked to a Learning OutcomeMedical Management and Collaborative Plan
6 pts
Proficient
Clearly and accurately describes concerns related to management and offers extensive collaborative planning involving several members of the healthcare team.
4 pts
Acceptable
Adequately describes concerns related to management and offers some collaborative planning involving members of the healthcare team.
2 pts
Needs Improvement
Vaguely describes concerns related to management and offers few collaborative planning involving members of the healthcare team.
1 pts
Unsatisfactory
Fails to describe concerns related to management and offers no collaborative planning.
6 pts
This criterion is linked to a Learning OutcomePatient Education, Discharge Planning, Referrals and Consults
6 pts
Proficient
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.
4 pts
Acceptable
Adequately identifies areas of instructional needs, learning preference and learning barriers. Provided some and adequate client education that aids in health promotion, health maintenance and self-care activities. Lists appropriate collaborative issue/concern Rationale and demonstrated limited understanding of consults and interventions.
2 pts
Needs Improvement
Vaguely identifies areas of instructional needs, learning preference, and learning barriers. Provided minimal and vague client education that will aid in health promotion, health maintenance, and self-care activities. Lists appropriate collaborative issue/concern Rationale and demonstrated vague understanding of consults and interventions.
1 pts
Unsatisfactory
Fails to identify areas of instructional needs, learning preference and learning barriers. Did not provide client education that will aid in health promotion, health maintenance and self-care activities. Lists inappropriate collaborative issues/concerns; rationale demonstrated unsatisfactory understanding of consults and intervention.
6 pts
This criterion is linked to a Learning OutcomeMedications
8 pts
Proficient
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 client.
6 pts
Acceptable
Adequately identifies components of the medication list. Adequate description of mechanism of action, purpose, range, side effects, interactions, safe dosing ranges, dosing calculation for min and max per weight of your patient, and nursing considerations relevant to the client.
4 pts
Needs Improvement
Vaguely identifies components of the medication list. Lacks description of mechanism of action, purpose, range side effects, interactions, safe dosing ranges, incorrect/missing dosing calculation for min and max per weight of your patient, and nursing considerations relevant to the client.
2 pts
Unsatisfactory
Fails to identify components of the medication list. Fails to include mechanism of action, purpose, range side effects, interactions, safe dosing ranges, incorrect/missing dosing calculation for min and max per weight of your patient, and nursing considerations relevant to the client.
8 pts
This criterion is linked to a Learning OutcomeAssessment & Review of the Systems
12 pts
Proficient
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 pts
Acceptable
Documents Head-to- Toe physical assessment – with approx. 75% + 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.
6 pts
Needs Improvement
Documents full Head-to- Toe physical assessment – with approx. 50% -75% relevant to the patient/client as performed by the student. Format may be moderately disorganized with mostly appropriate terms to describe both normal and abnormal assessment findings.
2 pts
Unsatisfactory
Documents full Head-to-Toe physical assessment – with approx. > 50% relevant to the patient/client missing information – as performed by the student. Format is mostly disorganized and may be lacking appropriate terms to describe both normal and abnormal assessment findings.
12 pts
This criterion is linked to a Learning OutcomeRecognizing Cues
4 pts
Proficient
Identifies imperative cues taken from the environment, patient observation, medical record, other resources, time pressures, task complexity, and cultural considerations.
3 pts
Acceptable
Identifies most imperative cues taken from the environment, patient observation, medical record, other resources, time pressures, task complexity, and cultural considerations.
2 pts
Needs Improvement
Identifies some imperative cues taken from the environment, patient observation, medical record, other resources, time pressures, task complexity, and cultural considerations.
1 pts
Unsatisfactory
Unable to identify imperative cues taken from the environment, patient observation, medical record, other resources, time pressures, task complexity, and cultural considerations.
4 pts
This criterion is linked to a Learning OutcomeAnalyzing Cues
4 pts
Proficient
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.
3 pts
Acceptable
Interprets cues from their existing knowledge base and nursing perspective, attempts to evaluate cues in terms of relevancy, importance, and interrelationship among other cues, and somewhat organizes cues in clusters to develop a group of probable client needs/concerns and problems.
2 pts
Needs Improvement
Interprets cues from their existing knowledge base and nursing perspective, struggles to evaluate cues in terms of relevancy, importance, and interrelationship among other cues, and cannot organize cues in clusters to develop a group of probable client needs/concerns and problems.
1 pts
Unsatisfactory
Fails to interpret cues from their existing knowledge base and nursing perspective, fails to evaluate cues in terms of relevancy, importance, and interrelationship among other cues, and does not organize cues in clusters to develop a group of probable client needs/concerns and problems.
4 pts
This criterion is linked to a Learning OutcomePrioritizes Hypotheses
4 pts
Proficient
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)
3 pts
Acceptable
Presents 3 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).
2 pts
Needs Improvement
Presents 2 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).
1 pts
Unsatisfactory
Fails to present probable client needs/concerns and problems generated and does not organize 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).
4 pts
This criterion is linked to a Learning OutcomeClinical Judgment
8 pts
Proficient
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.
6 pts
Acceptable
Adequately establishes 3 client outcome criteria and can be achieved with nursing assistance. The judgment somewhat supports the nursing diagnosis and plan of care. The judgments are somewhat measurable and realistic.
4 pts
Needs Improvement
Vaguely establishes 2 client outcome criteria and may or may not be achieved with nursing assistance. The judgments are inconsistent with the nursing diagnosis and plan of care. The judgments are vaguely realistic and measurable.
2 pts
Unsatisfactory
Fails to establish client’s outcome criteria that cannot be met by nursing assistance. The judgment lacks support and is nonspecific from gathered data, judgements are not realistic and not measurable.
8 pts
This criterion is linked to a Learning OutcomeGenerate Solutions & Rationale
6 pts
Proficient
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.
4.5 pts
Acceptable
Adequately identifies independent and collaborative solutions supported by scientific rationale and evidence-based practice. Solutions are adequate, individualized, organized, specific, and realistic. Solutions can be implemented adequately that are focused on clinical judgments based on nursing assessment.
3 pts
Needs Improvement
Vaguely Identifies solutions with unclear teaching. Scientific rationale is vaguely relevant & not supported by evidence-based practice. Solutions are inconsistent, non-specific, disorganized, and not adequately focused on clinical judgments. Solutions are difficult to implement and not based on nursing assessment.
1 pts
Unsatisfactory
Fails to identify solutions. Lacks scientific rationale and is not supported by evidence-based practice. Solutions are non-specific, inappropriate, unrealistic, and do not relate to clinical judgments. Solutions do not focus on clinical judgments and/or the stated health deviation based on nursing assessment.
6 pts
This criterion is linked to a Learning OutcomeTake Action
4 pts
Proficient
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.
3 pts
Acceptable
Adequately 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.
2 pts
Needs Improvement
Somewhat 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.
1 pts
Unsatisfactory
Fails to sort the actions (based on their evaluation in various dimensions) and carry out the action(s) to address the hypothesis/hypotheses with the highest priority first.
4 pts
This criterion is linked to a Learning OutcomeOutcome/Evaluation/Reflection
6 pts
Proficient
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.
4.5 pts
Acceptable
Adequately identifies criteria for evaluation. Adequately determines the effectiveness of actions taken against the clinical judgments with appropriate modification and revisions to the care plan.
3 pts
Needs Improvement
Difficulty utilizing criteria for evaluation. Difficulty determining the effectiveness of actions taken against the clinical judgments; evaluation vaguely supports if clinical judgments are met or not met with inaccurate revisions to the care plan.
1 pts
Unsatisfactory
Does not support nor utilize criteria for evaluation. Does not determine the effectiveness of actions taken against the clinical judgments. There is a lack of alternative actions to the care plan.
6 pts
This criterion is linked to a Learning OutcomeGeneral Organization
3 pts
Proficient
Accurate APA format, appropriate citations, and references, No spelling or grammar errors.
2 pts
Acceptable
Adequate APA format. Minimal citations and references are appropriate. Few spelling or grammar errors.
1 pts
Needs Improvement
Numerous APA format errors, Inaccurate citations, and references. Few spelling and grammar errors.
0 pts
Unsatisfactory
Fails to utilize APA format. No citations or references included numerous spelling and grammar errors.
3 pts
Total Points: 100

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