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RN Priority Problem #1:
R/T __________________________
Assessment Data
Admit Diagnosis: VS: Pertinent Labs: PMH: PSH: RN Priority Problem #2:
R/T __________________________ RN Priority Problem #3:
R/T __________________________ Goal : ______________________ (What do you hope to see happen on this shift? What do you hope to NOT happen, on this shift?) Outcome(s) Identified: (How will you measure whether the goal was achieved? Should be SMART โ specific, measurable, achievable, realistic, timely)
- Goal : ______________________ (What do you hope to see happen on this shift? What do you hope to NOT happen, on this shift?) Outcome(s) Identified: (How will you measure whether the goal was achieved? Should be SMART โ specific, measurable, achievable, realistic, timely) 1. __________________ 2. __________________ Goal : ______________________ (What do you hope to see happen on this shift? What do you hope to NOT happen, on this shift?) Outcome(s) Identified: (How will you measure whether the goal was achieved? Should be SMART โ specific, measurable, achievable, realistic, timely) 1. __________________ 2. __________________
RN Priority Problem #3: Interventions for Outcome #1: Outcome #1 ___________________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________ Interventions for Outcome #2: Outcome #2 ___________________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________ Interventions for Outcome #3: Outcome #3 ___________________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________ RN Priority Problem #1: Interventions for Outcome #1: Outcome #1 ___________________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________ Interventions for Outcome #2: Outcome #2 ___________________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________ Interventions for Outcome #3: Outcome #3 ___________________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________
a. Rationale__________________________________________________________ RN Priority Problem #2: Interventions for Outcome #1: Outcome #1 ___________________________________________________________________
b. Rationale__________________________________________________________
c. Rationale__________________________________________________________
d. Rationale__________________________________________________________ Interventions for Outcome #2: Outcome #2 ___________________________________________________________________
b. Rationale__________________________________________________________
c. Rationale__________________________________________________________
d. Rationale__________________________________________________________ Interventions for Outcome #3: Outcome #3 ___________________________________________________________________
b. Rationale__________________________________________________________
c. Rationale__________________________________________________________
d. Rationale__________________________________________________________
Evaluation:
Outcome Criteria for Problem #1, Outcome 1: Met / Not Met / In Progress (circle/highlight ONE)
- As Evidenced By: _____________________________________________________
Outcome Criteria for Problem #1, Outcome 2: Met / Not Met / In Progress (circle/highlight ONE)
- As Evidenced By: _____________________________________________________
Outcome Criteria for Problem #1, Outcome 3: Met / Not Met / In Progress (circle/highlight ONE)
- As Evidenced By: _____________________________________________________
Outcome Criteria for Problem #2, Outcome 1: Met / Not Met / In Progress (circle/highlight ONE)
- As Evidenced By: _____________________________________________________
Outcome Criteria for Problem #2, Outcome 2: Met / Not Met / In Progress (circle/highlight ONE)
- As Evidenced By: _____________________________________________________
Outcome Criteria for Problem #3, Outcome 3: Met / Not Met / In Progress (circle/highlight ONE)
- As Evidenced By: _____________________________________________________
Subjective Data: Objective Data:
