Professional Documents
Culture Documents
4 Gives concrete representation of the case Title fits the case Introduction outlines the case History is true to the case and reflects an enquiry to the case
3 Reflects the general representation of the case Title of the case is unique Introduction introduces the case History outlines the circumstances surrounding the case
2 Gives abstract representation of the case Title is a clear abstraction of the case Introduction gives the facts of the case History reflects the case but needs additional data to pinpoint specifics of the case
1 Neutral representation of the case Neutral title for the case Introduction gives the incidence of the case History haphazardly collected, an in depth inquiry is needed
SCORE
Reflects a clear outline of the case Introductio The introduction properly n introduces the case to the reader Patients Clearly outlines the History history and predisposition of the case Reflects in- depth analysis of the case Mental Clearly reflects the mental Assessment state of the client Physical Pertinent and relevant to the Assessment case Psychodyna mics Clearly outlines how and why of the case Theories are chosen to clearly explain the case Clearly reflects the circumstances that are pertinent to the case Ideally reflects how the patient can be ushered to the resolution of the identified problems Reflects patient centered approach Clearly reflects collaboration with the
Outlines the mental state of the client Physical assessment outlines the case Outlines the how of the client
Abstract mental pictures of client Physical assessment unreflective of the clients physical state Outline the why of the client
Specifics of the clients mental state not clearly outlined Physical assessment collected without specifics Outlines and traces the case
Mental state of the client is not clearly outlined Physical assessment irrelevant to the case Traces the progression of the case
Reflects the development and affects of the case Reflects the intervention to the problem Reflects care plan mandated by the nurse Other healthcare professionals
Interventions answer the problems identified by the nurse Reflects the nursecentered approach to
Does not reflect client, family and other healthcare professional collaboration Further improvement needed to allow collaboration for
Does not reflect anything about the case Does not reflect client participation Improvement needed to allow clientcentered problem identification
client, family and other health care professional concerned with client
Process Recording
Clearly reflects a therapeutic relationship between the nurse and the patient
Reflects a developing therapeutic relationship between the client and nurse Reflects lesson learned from the case Scrutiny is deep but presented resolutions are superficial Recommendations are lengthy and lacks specificity and guidance Organized and systematic Grammatical and typographical errors are obvious and obtrusive Indention observed on some paragraphs Paragraph organization needs to be developed
problem resolution Further improvement needed to allow client centered Nurse- client interaction reflects therapeutic emphases
Recommen dations
Contents
Clearly reflects the insights of a learned researcher Clearly reflects how best the researcher can resolve the case given another chance to do it all over again Specific and clearly guides the way how future researchers can best tackle the case on another occasion The contents are well organized Grammatically and typographical errors are minimal or none at all Indentions are observed all throughout the text of the portfolio Paragraphs are well organized and properly indented Clearly guides the reader through the unfolding of the case and its management
Nurse- client interaction is too impersonal for a therapeutic relationship to develop Insightful conclusion to the case lacking Scrutiny is irrelative to the case
Recommendations does not clearly guide how the case may be tackled in the future Paragraph disintegration is obviously reflected Grammatical and typographical errors are numerous Indentions are not observed in almost all entries
Recommendations are Recommendations numerous but further irrelevant to the case researches not encourage Scattered throughout progression observed Disorganization is obvious Indentions are lacking in all paragraphs Thought progression is unclear Looseness of association observed
References
Resources are numerous Variety of resources reflected Reflects current and updated resources Referencing system used is approved and recommended
Resources are at a minimum of 5 Reflects current and updated resources referencing system used is approved and recommended
Resources are kept to a minimum of 5 Current and updated resources needed Referencing system used is approved and recommended
Resources less than 5 Variety of resources needed Referencing system used is approved and recommended
CUES
NURSING DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION
THERAPEUTIC COMMUNICATION
RATIONALE
INTERPRETATION / ANALYSIS
REFLECTION/ SELF- AWARENESS: ___________________________________ _____________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
THERAPEUTIC COMMUNICATION
RATIONALE
INTERPRETATION / ANALYSIS
REFLECTION/ SELF- AWARENESS: ___________________________________ _____________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
THERAPEUTIC COMMUNICATION
RATIONALE
INTERPRETATION / ANALYSIS
REFLECTION/ SELF- AWARENESS: ___________________________________ _____________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________