I ordered this from other writer and he messed up, got 48/100 and failed have gi

I ordered this from other writer and he messed up, got 48/100 and failed have given few more hours to rewrite and resubmit it again following the rubric, waiting for the professor for more info which parts are missing specifically. Clinical Judgment Plan.1st file is the work that is done not completely and needs to be rewritten, 2nd is the same patient information I got from clinical from chart and assessment. and here ris the rubric. I am attaching an new form too if you need a new blank form.
Clinical Judgment Plan
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeHistory of Present Illness, pathophysiology of Admitting Diagnosis
5 ptsProficient
HPI explains in detail with accurate and in- depth understanding of chief complaint and supported by evidence-based citations.
4 ptsAcceptable
HPI explains in some detail with moderate understanding of chief complaint or no support from evidence-based citations.
3 ptsNeeds Improvement
HPI explains in limited detail with insufficient understanding of chief complaint or support from evidence-based citations.
2 ptsUnsatisfactory
HPI details limited with poor understanding of chief complaint and no evidence-based citations to support.
5 pts
This criterion is linked to a Learning OutcomePast Medical, Surgical, Social, and Obstetrical History Pathophysiology
8 ptsProficient
Past medical, surgical, social, and obstetrical history detailed with full explanation of pathophysiology for admitting diagnosis and for each diagnosis & accurate detail with specific detail related to the client’s history and symptoms and supported by evidence-based citations.
6 ptsAcceptable
Past medical, surgical, social, and obstetrical 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.
4 ptsNeeds Improvement
Past medical, surgical, social, and obstetrical 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.
2 ptsUnsatisfactory
No past medical, surgical, social, and obstetrical 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.
8 pts
This criterion is linked to a Learning OutcomeSocioeconomic, Psychosocial, and Cultural Assessment & Psychosocial Concerns
4 ptsProficient
Describes socioeconomic and cultural background in complete detail with references; identified 3 or more psychosocial concerns.
3 ptsAcceptable
Describes socioeconomic and cultural background with limited detail without references; identified 1-2 psychosocial concern.
2 ptsNeeds Improvement
Describes socioeconomic and cultural background in vague detail without references; identified 1 psychosocial concern.
1 ptsUnsatisfactory
Describes socioeconomic and cultural background with no detail without references; identified no psychosocial concerns.
4 pts
This criterion is linked to a Learning OutcomeErickson’s Developmental Stages
4 ptsProficient
Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidenced based citations.
3 ptsAcceptable
Identifies and defines correct stage with vague examples of meeting/not meeting tasks supported by evidenced citations.
2 ptsNeeds Improvement
Identifies correct stage without adequate definition and without examples of meeting or not meeting tasks. No citations
1 ptsUnsatisfactory
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 Test
8 ptsProficient
Clearly and accurately identifies pertinent laboratory tests with abnormal values and identifying trends related to a client’s disease process.
6 ptsAcceptable
Adequately identifies pertinent laboratory tests with abnormal values and identifying trends related to the client’s disease process.
4 ptsNeeds Improvement
Vaguely identifies pertinent laboratory tests with abnormal values and identifying trends related to the client’s disease process.
2 ptsUnsatisfactory
Fails to identify pertinent laboratory tests with abnormal values and identifying trends related to the client’s disease process.
8 pts
This criterion is linked to a Learning OutcomeMedical Management and Collaborative Plan
8 ptsProficient
Clearly and accurately describes concerns related to management and offers extensive collaborative planning involving several members of the healthcare team.
6 ptsAcceptable
Adequately describes concerns related to management and offers some collaborative planning involving members of the healthcare team.
4 ptsNeeds Improvement
Vaguely describes concerns related to management and offers few collaborative planning involving members of the healthcare team.
2 ptsUnsatisfactory
Fails to describe concerns related to management and offers no collaborative planning.
8 pts
This criterion is linked to a Learning OutcomePatient Education, Discharge Planning, Referrals and Consults
8 ptsProficient
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.
6 ptsAcceptable
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.
4 ptsNeeds 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.
2 ptsUnsatisfactory
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.
8 pts
This criterion is linked to a Learning OutcomeMedications
8 ptsProficient
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.
6 ptsAcceptable
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.
4 ptsNeeds Improvement
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.
2 ptsUnsatisfactory
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.
8 pts
This criterion is linked to a Learning OutcomeAssessment & Review of the Systems
8 ptsProficient
Documents full Head-to-Toe physical assessment – relevant to the patient/client as performed by the student. Includes postpartum assessment and information on neonate. Utilizes an organized format and appropriate terms to describe both normal and abnormal assessment findings.
6 ptsAcceptable
Documents Head-to-Toe physical assessment – with approx. 75% + relevant to the patient/client as performed by the student. Includes postpartum assessment and information on neonate. Utilizes an organized format and appropriate terms to describe both normal and abnormal assessment findings.
4 ptsNeeds Improvement
Documents full Head-to-Toe physical assessment – with approx. 50% -75% relevant to the patient/client as performed by the student. Includes postpartum assessment and information on neonate. Format may be moderately disorganized with mostly appropriate terms to describe both normal and abnormal assessment findings.
2 ptsUnsatisfactory
Documents full Head-to-Toe physical assessment – with approx. > 50% relevant to the patient/client missing information – as performed by the student. Does not include postpartum assessment and information on neonate. Format is mostly disorganized and may be lacking appropriate terms to describe both normal and abnormal assessment findings.
8 pts
This criterion is linked to a Learning OutcomeRecognizing Cues
4 ptsProficient
Identifies imperative cues taken from the environment, patient observation, medical record, other resources, time pressures, task complexity, and cultural considerations.
3 ptsAcceptable
Identifies most imperative cues taken from the environment, patient observation, medical record, other resources, time pressures, task complexity, and cultural considerations.
2 ptsNeeds Improvement
Identifies some imperative cues taken from the environment, patient observation, medical record, other resources, time pressures, task complexity, and cultural considerations.
1 ptsUnsatisfactory
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 OutcomeAnalyze Cues
4 ptsProficient
Interprets cues from their existing knowledge base and nursing perspective, successfully evaluate cues in terms of relevancy, importance, and interrelationship among other cues, organizes cues in clusters to develop a group of probable client needs/concerns and problems.
3 ptsAcceptable
Interprets cues from their existing knowledge base and nursing perspective, attempts to evaluate cues in terms of relevancy, importance, and interrelationship among other cues, somewhat organizes cues in clusters to develop a group of probable client needs/concerns and problems.
2 ptsNeeds 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, cannot organize cues in clusters to develop a group of probable client needs/concerns and problems.
1 ptsUnsatisfactory
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, 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 ptsProficient
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 ptsAcceptable
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 ptsNeeds 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 ptsUnsatisfactory
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 ptsProficient
Clearly and accurately establishes 4 client’s outcome criteria and can be achieved with nursing assistance. The judgements clearly support the clinical decisions and plan of care. The judgements are easily measurable and realistic.
6 ptsAcceptable
Adequately establishes 3 client’s outcome criteria and can be achieved with nursing assistance. The judgement somewhat supports the nursing diagnosis and plan of care. The judgements are somewhat measurable and realistic.
4 ptsNeeds Improvement
Vaguely establishes 2 client’s outcome criteria and may or may not be achieved with nursing assistance. The judgements are inconsistent with the nursing diagnosis and plan of care. The judgements are vaguely realistic and measurable.
2 ptsUnsatisfactory
Fails to establish client’s outcome criteria that cannot be met by nursing assistance. The judgement lack support and nonspecific from gathered data, judgements are not realistic and not measurable.
8 pts
This criterion is linked to a Learning OutcomeGenerate Solutions & Rationale
4 ptsProficient
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 the clinical judgements and directed at the stated health deviation based on nursing assessment.
3 ptsAcceptable
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 judgements based on nursing assessment.
2 ptsNeeds 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 the clinical judgements. Solutions are difficult to implement and not based on nursing assessment.
1 ptsUnsatisfactory
Fails to identify solutions. Lack scientific rationale and is not supported by evidence-based practice. Solutions are non-specific, inappropriate, unrealistic, and do not relate to the clinical judgments. Solutions do not focus on clinical judgements and/or the stated health deviation based on nursing assessment.
4 pts
This criterion is linked to a Learning OutcomeTake Action
4 ptsProficient
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 highest priority first.
3 ptsAcceptable
Adequately sorts the actions (based on their evaluation in various dimensions) and carries out the action(s) to address the hypothesis/hypotheses with highest priority first.
2 ptsNeeds Improvement
Somewhat sorts the actions (based on their evaluation in various dimensions) and carries out the action(s) to address the hypothesis/hypotheses with highest priority first.
1 ptsUnsatisfactory
Fails to sort the actions (based on their evaluation in various dimensions) and carries out the action(s) to address the hypothesis/hypotheses with highest priority first.
4 pts
This criterion is linked to a Learning OutcomeEvaluation/Reflection
8 ptsProficient
Skillfully and independently identifies criteria for evaluation. Evaluates effectiveness of actions taken against the clinical judgements; modifies, revises, and recommends alternative actions as needed.
6 ptsAcceptable
Adequately identifies criteria for evaluation. Adequately determines effectiveness of actions taken against the clinical judgements with appropriate modification and revisions to the care plan.
4 ptsNeeds Improvement
Difficulty utilizing criteria for evaluation. Difficulty determining effectiveness of actions taken against the clinical judgements; evaluation vaguely supports if clinical judgements are met or not met with inaccurate revisions to the care plan.
2 ptsUnsatisfactory
Does not support nor utilize criteria for evaluation. Does not determine effectiveness of actions taken against the clinical judgements. There is a lack of alternative actions to the care plan.
8 pts
This criterion is linked to a Learning OutcomeGeneral Organization
3 ptsProficient
Accurate APA format, appropriate citations, and references, No spelling or grammar errors.
2 ptsAcceptable
Adequate APA format. Minimal citations and references are appropriate. Few spellings or grammar errors.
1 ptsNeeds Improvement
Numerous APA format errors, Inaccurate citations, and references. Few spelling and grammar errors.
0 ptsUnsatisfactory
Fails to utilize APA format. No citations or references included numerous spelling and grammar errors.
3 pts
Total Points: 100