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Name: Psychiatric Care Plan Rubric

 

Meets or Exceeds Mostly Meets Approaches Does Not Meet Expectations
Client’s Demographics and Psychiatric Legal Status Points: 5 (5.00%) Clearly and accurately describes the client’s demographics and psychiatric legal status in detail. Feedback: Points: 3.8 (3.80%) Adequately describes the client demographics and psychiatric legal status with adequate detail. Feedback: Points: 2.5 (2.50%) Vaguely describes the client’s demographics and psychiatric legal status with some detail. Feedback: Points: 1.25 (1.25%) Lack description of the client’s demographics and psychiatric legal status that presents no detail. Feedback:
Client’s Vital Signs and Allergies Points: 5 (5.00%) Clearly and accurately documented the client’s vital signs and allergies in full detail. Feedback: Points: 3.8 (3.80%) Adequately documented the client’s vital signs and allergies. Missing few minor details. Feedback: Points: 2.5 (2.50%) Incomplete documentation of the client’s vital signs and allergies. Feedback: Points: 1.25 (1.25%) Fails to document the client’s vital signs and allergies. Feedback:
History of Present Illness and Multiaxial Diagnostic System Points: 6 (6.00%) Clearly and accurately describes the client’s history of present illness. The Multiaxial Diagnostic System clearly and accurately supports the identified chief complaint and presenting signs/symptoms. Feedback: Points: 4.56 (4.56%) Adequately describes the client’s history of present illness. The Multiaxial Diagnostic System adequately supports the identified chief complaint and presenting signs/symptoms. Feedback: Points: 3 (3.00%) Vaguely describes the client’s history of present illness. The Multiaxial Diagnostic System vaguely supports the identified chief complaint and presenting signs/symptoms. Feedback: Points: 1.5 (1.50%) Lack description of client’s history of present illness. The Multiaxial Diagnostic System does not support the identified chief complaint and presenting signs/symptoms. Feedback:
Psychopathology and biophysical pathology of admitting and/or related psychiatric and medical diagnosis Points: 6 (6.00%) Clearly and accurately identifies psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms. Feedback: Points: 4.56 (4.56%) Adequately identifies psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms. Feedback: Points: 3 (3.00%) Vaguely identifies psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms. Feedback: Points: 1.5 (1.50%) Fails to identify psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms. Feedback:
Erikson’s Developmental Stages Points: 6 (6.00%) Clearly and accurately identifies client’s developmental stage with rationales based on the client’s developmental tasks. Feedback: Points: 4.56 (4.56%) Adequately identifies client’s developmental stage with rationales based on the client’s developmental tasks. Feedback: Points: 3 (3.00%) Vaguely identifies client’s developmental stage without adequate rationale based on the client’s developmental tasks. Feedback: Points: 1.5 (1.50%) Fail to identify client’s developmental stage and lack rationale based on the client’s developmental tasks. Feedback:
Mental Status Examination Points: 6 (6.00%) Clearly and accurately describes all components of the mental status examination based on the client’s presenting symptoms. Feedback: Points: 4.56 (4.56%) Adequately describes components of the mental status examination based on the client’s presenting symptoms. Feedback: Points: 1.5 (1.50%) Vaguely describes components of the mental status examination based on the client’s presenting symptoms. Feedback: Points: 0 (0.00%) Fails to describe any of components of the mental status examination based on the client’s presenting symptoms. Feedback:
Substance Abuse and other Addictions Points: 6 (6.00%) Clearly and accurately identifies abused substances and problems associated with substance and other addictions. Feedback: Points: 4.56 (4.56%) Adequately identifies abused substances and problems associated with substance and other addictions. Feedback: Points: 3 (3.00%) Vaguely identifies abused substances and problems associated with substance and other addictions. Feedback: Points: 1.5 (1.50%) Fails to identify abused substances and problems associated with substance and other addictions. Feedback:
Risk Assessment Points: 6 (6.00%) Clearly and accurately identifies all risk factors related to the client’s history and presenting symptoms. Feedback: Points: 4.56 (4.56%) Adequately identifies some risk factors related to the client’s history and presenting symptoms. Feedback: Points: 3 (3.00%) Vaguely identifies risk factors related to the client’s history and presenting symptoms. Feedback: Points: 1.5 (1.50%) Fails to identify any of the risk factors related to the client’s history and presenting symptoms. Feedback:
Multidisciplinary Client Outcome & Discharge Planning. Points: 6 (6.00%) Clearly and accurately describes collaborative issues and concerns related multidisciplinary client outcome and discharge planning. Feedback: Points: 4.56 (4.56%) Adequately describes collaborative issues and concerns related multidisciplinary client outcome and discharge planning. Feedback: Points: 3 (3.00%) Vaguely describes collaborative issues and concerns related multidisciplinary client outcome and discharge planning. Feedback: Points: 1.5 (1.50%) Fails to describe collaborative issues and concerns related multidisciplinary outcome and discharge planning. Feedback:
Learning Needs Assessment and Client Education Points: 6 (6.00%) Clearly and accurately identifies areas of instructional needs, learning preference and learning barriers. Provided clear and concise client education the will aid in health promotion, health maintenance and self-care activities. Feedback: Points: 4.56 (4.56%) Adequately identifies areas of instructional needs, learning preference and learning barriers. Provided some and adequate client education the will aid in health promotion, health maintenance and self-care activities. Feedback: Points: 3 (3.00%) Vaguely identifies areas of instructional needs, learning preference and learning barriers. Provided minimal and vague client education the will aid in health promotion, health maintenance and self-care activities. Feedback: Points: 1.5 (1.50%) Fails to identify areas of instructional needs, learning preference and learning barriers. Did not provide client education the will aid in health promotion, health maintenance and self-care activities. Feedback:
Pertinent Lab Test & Abnormal Involuntary Movement Points: 6 (6.00%) Clearly and accurately identifies pertinent laboratory test and abnormal movements related to client’s disease process. Feedback: Points: 4.56 (4.56%) Adequately identifies pertinent laboratory test and abnormal movements related to client’s disease process. Feedback: Points: 1.5 (1.50%) Vaguely identifies pertinent laboratory test and abnormal movements related to client’s disease process. Feedback: Points: 0 (0.00%) Fails to identify pertinent laboratory test and abnormal movements related to client’s disease process. Feedback:
NANDA Nursing Diagnosis (prioritized) Nursing Diagnosis Definition Points: 6 (6.00%) Both nursing diagnoses are accurate and prioritized per NANDA format with clear etiology and data to support diagnosis. Clear and accurate nursing diagnosis definition. Feedback: Points: 4.56 (4.56%) Both nursing diagnoses are adequate and prioritized per NANDA format with sufficient etiology and data to support diagnosis. Adequate nursing diagnosis definition. Feedback: Points: 3 (3.00%) Both nursing diagnosis are vague and not prioritized per NANDA format with vague etiology and unclear correlation with the assessment data. Inaccurate nursing diagnosis definition. Feedback: Points: 1.5 (1.50%) Both nursing diagnosis are indefinable per NANDA format and do not correlate with assessment data. Lack nursing diagnosis definition. Feedback:
Nursing Outcome Criteria Points: 6 (6.00%) Clearly and accurately establishes client’s outcome criteria and can be achieved with nursing assistance. The goal clearly supports the nursing diagnosis and plan of care. The goals are easily measurable and realistic. Feedback: Points: 4.56 (4.56%) Adequately establishes client’s outcome criteria and can be achieved with nursing assistance. The goal somewhat supports the nursing diagnosis and plan of care. The goals are somewhat measurable and realistic. Feedback: Points: 3 (3.00%) Vaguely establishes client’s outcome criteria and may or may not be achieved with nursing assistance. The goals are inconsistent with the nursing diagnosis and plan of care. The goals are vaguely realistic and measurable. Feedback: Points: 1.5 (1.50%) Fails to establish client’s outcome criteria that cannot be met by nursing assistance. The goals lack support and nonspecific from gathered data, Outcome criteria are not realistic and not measurable. Feedback:
Nursing Intervention Criteria & Rationale Points: 6 (6.00%) Clearly and accurately Identifies independent nursing interventions criteria with teaching supported by scientific rationale and evidence- based practice. Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the client’s goals and directed at the stated health deviation based on nursing assessment and Erickson’s stages of development. Feedback: Points: 4.56 (4.56%) Adequately Identifies nursing interventions with adequate teaching. Scientific rationale is adequately supported by evidence-based practice. Interventions are adequate, individualized, organized, specific and realistic. Interventions can be implemented adequately that is focused on client’s goal and health deviation based on nursing assessment and Erickson’s stages of development. Feedback: Points: 3 (3.00%) Vaguely Identifies nursing interventions with unclear teaching. Scientific rationale is vaguely relevant & not supported by evidence-based practice. Interventions are inconsistent, non-specific, disorganized, and not adequately focused on the client’s goal. Interventions are difficult to implement and has weak relationship to nursing diagnosis based on nursing assessment and Erickson’s stages of development. Feedback: Points: 1.5 (1.50%) Fails to identify interventions and teaching. Lack Scientific rationale and is not supported by evidence-based practice. Interventions are non- specific, inappropriate, unrealistic, un-measurable and do not relate to nursing diagnosis. Intervention does do not focus on client goals and/or the stated health deviation based on nursing assessment and Erickson’s stages of development. Feedback:
Evaluation Points: 6 (6.00%) Skillfully and independently identifies criteria for evaluation. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative intervention. Feedback: Points: 4.56 (4.56%) Adequately identifies criteria for evaluation. Adequately determines effectiveness of nursing interventions and measures goal completion with appropriate modification and revisions to the treatment plan. Feedback: Points: 3 (3.00%) Difficulty utilizing criteria for evaluation. Difficulty determining effectiveness of interventions and goal completion. Evaluation vaguely supports if goal is met or not met with inaccurate revisions to the treatment plan. Feedback: Points: 1.5 (1.50%) Does not support nor utilize criteria for evaluation. Does not determine effectiveness of interventions and goal completion. There is a lack of alternative interventions to the treatment plan. Feedback:
Medications Points: 6 (6.00%) Clearly and accurately identifies all components of the medication list, including mechanism of action, purpose, range, side effects, interactions, levels and nursing considerations relevant to the client. Feedback: Points: 4.56 (4.56%) Adequately identifies components of the medication list. Adequate description of mechanism of action, purpose, range, side effects, interactions, levels and nursing considerations relevant to the client. Feedback: Points: 3 (3.00%) Vaguely identifies components of the medication list. Lack description of mechanism of action, purpose, range side effects, interactions, levels and nursing considerations relevant to the client. Feedback: Points: 1.5 (1.50%) Fails to identify components of the medication list. Failed to include mechanism of action, purpose, range side effects, interactions, levels and nursing considerations relevant to the client. Feedback:
General Organization Points: 6 (6.00%) Accurate APA format, Appropriate citations & references,No spelling or grammar errors Feedback: Points: 4.56 (4.56%) Adequate APA format. Minimal citations and references are appropriate. Few spelling or grammar errors. Feedback: Points: 3 (3.00%) Numerous APA format errors, Inaccurate citations and references. Few spelling and grammar errors. Feedback: Points: 1.5 (1.50%) Fails to utilize APA format. No citations or references included numerous spelling and grammar errors. Feedback:

Show Descriptions Show Feedback

Client’s Demographics and Psychiatric Legal Status–

Levels of Achievement: Meets or Exceeds 5 (5.00%) points Clearly and accurately describes the client’s demographics and psychiatric legal status in detail. Mostly Meets 3.8 (3.80%) points Adequately describes the client demographics and psychiatric legal status with adequate detail. Approaches 2.5 (2.50%) points Vaguely describes the client’s demographics and psychiatric legal status with some detail. Does Not Meet Expectations  1.25 (1.25%) points Lack description of the client’s demographics and psychiatric legal status that presents no detail. Feedback:

Client’s Vital Signs and Allergies–

Levels of Achievement: Meets or Exceeds 5 (5.00%) points Clearly and accurately documented the client’s vital signs and allergies in full detail. Mostly Meets 3.8 (3.80%) points Adequately documented the client’s vital signs and allergies. Missing few minor details. Approaches 2.5 (2.50%) points Incomplete documentation of the client’s vital signs and allergies. Does Not Meet Expectations  1.25 (1.25%) points Fails to document the client’s vital signs and allergies. Feedback:

History of Present Illness and Multiaxial Diagnostic System–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately describes the client’s history of present illness. The Multiaxial Diagnostic System clearly and accurately supports the identified chief complaint and presenting signs/symptoms. Mostly Meets 4.56 (4.56%) points Adequately describes the client’s history of present illness. The Multiaxial Diagnostic System adequately supports the identified chief complaint and presenting signs/symptoms. Approaches 3 (3.00%) points Vaguely describes the client’s history of present illness. The Multiaxial Diagnostic System vaguely supports the identified chief complaint and presenting signs/symptoms. Does Not Meet Expectations  1.5 (1.50%) points Lack description of client’s history of present illness. The Multiaxial Diagnostic System does not support the identified chief complaint and presenting signs/symptoms. Feedback:

Psychopathology and biophysical pathology of admitting and/or related psychiatric and medical diagnosis–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately identifies psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms. Mostly Meets 4.56 (4.56%) points Adequately identifies psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms. Approaches 3 (3.00%) points Vaguely identifies psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms. Does Not Meet Expectations  1.5 (1.50%) points Fails to identify psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms. Feedback:

Erikson’s Developmental Stages–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately identifies client’s developmental stage with rationales based on the client’s developmental tasks. Mostly Meets 4.56 (4.56%) points Adequately identifies client’s developmental stage with rationales based on the client’s developmental tasks. Approaches 3 (3.00%) points Vaguely identifies client’s developmental stage without adequate rationale based on the client’s developmental tasks. Does Not Meet Expectations  1.5 (1.50%) points Fail to identify client’s developmental stage and lack rationale based on the client’s developmental tasks. Feedback:

Mental Status Examination–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately describes all components of the mental status examination based on the client’s presenting symptoms. Mostly Meets 4.56 (4.56%) points Adequately describes components of the mental status examination based on the client’s presenting symptoms. Approaches 1.5 (1.50%) points Vaguely describes components of the mental status examination based on the client’s presenting symptoms. Does Not Meet Expectations  0 (0.00%) points Fails to describe any of components of the mental status examination based on the client’s presenting symptoms. Feedback:

Substance Abuse and other Addictions–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately identifies abused substances and problems associated with substance and other addictions. Mostly Meets 4.56 (4.56%) points Adequately identifies abused substances and problems associated with substance and other addictions. Approaches 3 (3.00%) points Vaguely identifies abused substances and problems associated with substance and other addictions. Does Not Meet Expectations  1.5 (1.50%) points Fails to identify abused substances and problems associated with substance and other addictions. Feedback:

Risk Assessment–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately identifies all risk factors related to the client’s history and presenting symptoms. Mostly Meets 4.56 (4.56%) points Adequately identifies some risk factors related to the client’s history and presenting symptoms. Approaches 3 (3.00%) points Vaguely identifies risk factors related to the client’s history and presenting symptoms. Does Not Meet Expectations  1.5 (1.50%) points Fails to identify any of the risk factors related to the client’s history and presenting symptoms. Feedback:

Multidisciplinary Client Outcome & Discharge Planning.–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately describes collaborative issues and concerns related multidisciplinary client outcome and discharge planning. Mostly Meets 4.56 (4.56%) points Adequately describes collaborative issues and concerns related multidisciplinary client outcome and discharge planning. Approaches 3 (3.00%) points Vaguely describes collaborative issues and concerns related multidisciplinary client outcome and discharge planning. Does Not Meet Expectations  1.5 (1.50%) points Fails to describe collaborative issues and concerns related multidisciplinary outcome and discharge planning. Feedback:

Learning Needs Assessment and Client Education–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately identifies areas of instructional needs, learning preference and learning barriers. Provided clear and concise client education the will aid in health promotion, health maintenance and self-care activities. Mostly Meets 4.56 (4.56%) points Adequately identifies areas of instructional needs, learning preference and learning barriers. Provided some and adequate client education the will aid in health promotion, health maintenance and self-care activities. Approaches 3 (3.00%) points Vaguely identifies areas of instructional needs, learning preference and learning barriers. Provided minimal and vague client education the will aid in health promotion, health maintenance and self-care activities. Does Not Meet Expectations  1.5 (1.50%) points Fails to identify areas of instructional needs, learning preference and learning barriers. Did not provide client education the will aid in health promotion, health maintenance and self-care activities. Feedback:

Pertinent Lab Test & Abnormal Involuntary Movement–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately identifies pertinent laboratory test and abnormal movements related to client’s disease process. Mostly Meets 4.56 (4.56%) points Adequately identifies pertinent laboratory test and abnormal movements related to client’s disease process. Approaches 1.5 (1.50%) points Vaguely identifies pertinent laboratory test and abnormal movements related to client’s disease process. Does Not Meet Expectations  0 (0.00%) points Fails to identify pertinent laboratory test and abnormal movements related to client’s disease process. Feedback:

NANDA Nursing Diagnosis (prioritized) Nursing Diagnosis Definition–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Both nursing diagnoses are accurate and prioritized per NANDA format with clear etiology and data to support diagnosis. Clear and accurate nursing diagnosis definition. Mostly Meets 4.56 (4.56%) points Both nursing diagnoses are adequate and prioritized per NANDA format with sufficient etiology and data to support diagnosis. Adequate nursing diagnosis definition. Approaches 3 (3.00%) points Both nursing diagnosis are vague and not prioritized per NANDA format with vague etiology and unclear correlation with the assessment data. Inaccurate nursing diagnosis definition. Does Not Meet Expectations  1.5 (1.50%) points Both nursing diagnosis are indefinable per NANDA format and do not correlate with assessment data. Lack nursing diagnosis definition. Feedback:

Nursing Outcome Criteria–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately establishes client’s outcome criteria and can be achieved with nursing assistance. The goal clearly supports the nursing diagnosis and plan of care. The goals are easily measurable and realistic. Mostly Meets 4.56 (4.56%) points Adequately establishes client’s outcome criteria and can be achieved with nursing assistance. The goal somewhat supports the nursing diagnosis and plan of care. The goals are somewhat measurable and realistic. Approaches 3 (3.00%) points Vaguely establishes client’s outcome criteria and may or may not be achieved with nursing assistance. The goals are inconsistent with the nursing diagnosis and plan of care. The goals are vaguely realistic and measurable. Does Not Meet Expectations  1.5 (1.50%) points Fails to establish client’s outcome criteria that cannot be met by nursing assistance. The goals lack support and nonspecific from gathered data, Outcome criteria are not realistic and not measurable. Feedback:

Nursing Intervention Criteria & Rationale–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately Identifies independent nursing interventions criteria with teaching supported by scientific rationale and evidence- based practice. Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the client’s goals and directed at the stated health deviation based on nursing assessment and Erickson’s stages of development. Mostly Meets 4.56 (4.56%) points Adequately Identifies nursing interventions with adequate teaching. Scientific rationale is adequately supported by evidence-based practice. Interventions are adequate, individualized, organized, specific and realistic. Interventions can be implemented adequately that is focused on client’s goal and health deviation based on nursing assessment and Erickson’s stages of development. Approaches 3 (3.00%) points Vaguely Identifies nursing interventions with unclear teaching. Scientific rationale is vaguely relevant & not supported by evidence-based practice. Interventions are inconsistent, non-specific, disorganized, and not adequately focused on the client’s goal. Interventions are difficult to implement and has weak relationship to nursing diagnosis based on nursing assessment and Erickson’s stages of development. Does Not Meet Expectations  1.5 (1.50%) points Fails to identify interventions and teaching. Lack Scientific rationale and is not supported by evidence-based practice. Interventions are non- specific, inappropriate, unrealistic, un-measurable and do not relate to nursing diagnosis. Intervention does do not focus on client goals and/or the stated health deviation based on nursing assessment and Erickson’s stages of development. Feedback:

Evaluation–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Skillfully and independently identifies criteria for evaluation. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative intervention. Mostly Meets 4.56 (4.56%) points Adequately identifies criteria for evaluation. Adequately determines effectiveness of nursing interventions and measures goal completion with appropriate modification and revisions to the treatment plan. Approaches 3 (3.00%) points Difficulty utilizing criteria for evaluation. Difficulty determining effectiveness of interventions and goal completion. Evaluation vaguely supports if goal is met or not met with inaccurate revisions to the treatment plan. Does Not Meet Expectations  1.5 (1.50%) points Does not support nor utilize criteria for evaluation. Does not determine effectiveness of interventions and goal completion. There is a lack of alternative interventions to the treatment plan. Feedback:

Medications–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Clearly and accurately identifies all components of the medication list, including mechanism of action, purpose, range, side effects, interactions, levels and nursing considerations relevant to the client. Mostly Meets 4.56 (4.56%) points Adequately identifies components of the medication list. Adequate description of mechanism of action, purpose, range, side effects, interactions, levels and nursing considerations relevant to the client. Approaches 3 (3.00%) points Vaguely identifies components of the medication list. Lack description of mechanism of action, purpose, range side effects, interactions, levels and nursing considerations relevant to the client. Does Not Meet Expectations  1.5 (1.50%) points Fails to identify components of the medication list. Failed to include mechanism of action, purpose, range side effects, interactions, levels and nursing considerations relevant to the client. Feedback:

General Organization–

Levels of Achievement: Meets or Exceeds 6 (6.00%) points Accurate APA format, Appropriate citations & references,No spelling or grammar errors Mostly Meets 4.56 (4.56%) points Adequate APA format. Minimal citations and references are appropriate. Few spelling or grammar errors. Approaches 3 (3.00%) points Numerous APA format errors, Inaccurate citations and references. Few spelling and grammar errors. Does Not Meet Expectations  1.5 (1.50%) points Fails to utilize APA format. No citations or references included numerous spelling and grammar errors. Feedback:

Name:Psychiatric Care Plan Rubric

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