Complete past medical history, family medical history, VS, medication list inclu

Complete past medical history, family medical history, VS, medication list including frequency; route, dose, and height, weight, allergies and BMI Complete review of systems including specialties as appropriate Identified examples in the three stimuli areas: Focal, Contextual and Residual Complete list of diagnostic testing and laboratory data Complete S (Situation), B (Background), A (Assessment) and R (Recommendation) handout report Inclusion of subjective and objective data related to the individual that is specific to the Nursing Diagnosis Included NANDA approved Nursing Diagnosis, which included Related to and Manifested by statements • The NANDA Nursing Diagnosis was supported by rationale Includes a clear, measurable, achievable long-term goal specifically related to the Nursing Diagnosis Includes clear concise, specific, individualized and accomplishable interventions Includes a detailed rationale for every intervention Includes a complete discussion of the individual’s response to the intervention and any recommendations for changes to the intervention to enable the individual to meet the goal/outcomes identified.