A nursing evaluation is an essential part of the nursing process that helps you track your patient’s progress. Whether you’re a new nurse just learning the ropes or an experienced one refining your skills, knowing how to evaluate your nursing care will help you improve patient outcomes and your professional growth.
In this guide, you’ll find clear examples, practical tips, and easy-to-follow steps for mastering the nursing evaluation process. Let’s dive into how you can use this crucial tool to enhance your nursing practice.
What Is a Nursing Evaluation?
A nursing evaluation is the process where you check if the care you gave a patient worked. It’s the final step in the nursing process (ADPIE/ADOPIE) and answers the question: Did the patient’s care goals get met?
The main goal of nursing evaluation is to compare what was expected to what actually happened. If things didn’t go as planned, it helps identify what needs to be changed. Evaluation also helps nurses communicate better with each other and ensures patients are getting the best care possible.
Why Nursing Evaluation Is Important
- Measuring Progress: It shows whether the care goals were met, partially met, or not met.
- Accountability: If the goals weren’t met, the evaluation helps you change the care plan and keep moving forward.
- Better Communication: A clear evaluation helps the next nurse understand what worked and what didn’t, so they can continue the right treatment.
- Patient Safety: Accurate evaluations help prevent mistakes and make sure care stays on the right track.
How to Write a Nursing Evaluation Comment
Writing a nursing evaluation comment is an important skill. It should clearly explain the patient’s progress, whether things went well or not. Here’s how to make it easy.
What to Include in a Nursing Evaluation Comment
- Date and Time: Write down when you made the observation.
- Expected Outcome: What did you want to happen with the patient’s care?
- What Actually Happened: Use numbers or details to explain what happened (like pain levels or test results).
- Goal Status: Was the goal met, partly met, or not met?
- Next Step: What are you going to do next based on the outcome?
A Simple Formula to Follow
To make it simple, here’s a formula you can follow:
[Date/Time]: [What Happened] [Details]; goal [status]. Plan: [Next Step].
This keeps your comment clear, easy to follow, and ensures everything gets documented properly for the next nurse.
Example of a Nursing Evaluation Comment
Goal: Patient will report pain ≤3/10 within 24 hours.
Evaluation: “09/30 0700: Patient reports pain 2/10 after medication; goal met. Plan: Continue oral analgesics and reassess every 8 hours.”
Real-Life Examples of Nursing Evaluations
Now, let’s dive into some real-world examples of nursing evaluations. This is where the rubber meets the road — you’ll see how the nursing evaluation process looks when you’re actually applying it to patient care.
Pain Management Example:
- Goal: Patient will report pain ≤3/10 within 24 hours.
- Evaluation:
“09/30 0700: Patient reports pain 2/10 after medication; goal met. Plan: Continue oral analgesics and reassess every 8 hours.”
Fall Risk Prevention Example:
- Goal: Patient will remain free from falls during the shift.
- Evaluation:
“09/30 1930: No falls reported; patient used call bell before ambulating. Goal met. Plan: Reinforce safety teaching and continue hourly rounds.”
Respiratory Example:
- Goal: SpO₂ ≥ 92% on room air.
- Evaluation:
“09/30 1200: SpO₂ 95% on room air; goal met. Plan: Continue to monitor.”
These examples follow the evaluation formula mentioned earlier. They’re straightforward, clear, and make it easy for anyone reading the evaluation to know exactly what’s happening with the patient’s care.
Nursing Evaluation Examples Based on Diagnoses
In nursing practice, evaluations are often based on specific nursing diagnoses. These diagnoses help guide patient care and set clear goals. Let’s look at how nursing evaluations can differ depending on the diagnosis and how you can adjust your care plan based on the results.
Pain Management (Nursing Diagnosis)
- Goal Met:
“Pain 2/10 after analgesic; goal met. Continue reassessment every 8 hours.” - Partially Met:
“Pain 4/10 with movement; goal partially met. Extend timeframe and add non-pharm interventions.” - Not Met:
“Pain 7/10 despite intervention; goal not met. Notify provider, adjust care plan.”
Fall Risk (Nursing Diagnosis)
- Goal Met:
“No falls during shift; patient used call bell appropriately; goal met.” - Partially Met:
“Patient needed reminders to use walker; no falls occurred; goal partially met.” - Not Met:
“Patient attempted to ambulate unassisted and nearly fell; goal not met. Reinforce safety teaching.”
Impaired Gas Exchange (Nursing Diagnosis)
- Goal Met:
“SpO₂ 95% on room air; goal met. Plan: Continue to monitor.” - Partially Met:
“SpO₂ 91% on 2 L NC; goal partially met. Increase incentive spirometry use.” - Not Met:
“SpO₂ 88% despite O₂ therapy; goal not met. Notify provider.”
Nursing Evaluation Examples in Different Documentation Formats
Different healthcare settings might require different formats for documenting nursing evaluations. While the core idea remains the same, each format has its unique structure. Let’s go over some of the most common formats and how they include the nursing evaluation process.
SOAP Notes
SOAP stands for:
- Subjective
- Objective
- Assessment
- Plan
Some facilities add an E for Evaluation, making it SOAPIE. Here’s how it works:
Example:
“E: Pain reduced from 7/10 to 2/10 after intervention; goal met.”
SOAP notes are useful for documenting patient information and evaluations in a straightforward, structured way.
SOAPIE Notes
SOAPIE adds two more elements to the SOAP format:
- Intervention
- Evaluation
Example:
“E: Goal not met; SpO₂ remains 90–91% on 2 L NC. Plan to increase IS frequency.”
SOAPIE notes allow you to document the evaluation along with the interventions, which is especially useful for more complex cases.
PIE Charting
PIE stands for:
- Problem
- Intervention
- Evaluation
Example:
“E: Ambulated 30 ft with assistance; goal partially met. Extend timeframe.”
PIE charting is a direct and simple way to document the problem, the intervention, and the evaluation.
Narrative Notes
Narrative notes are written in paragraph form and give you more freedom to describe the patient’s condition. They’re less structured than other formats but still include important evaluation information.
Example:
“Patient ambulated hallway using walker. No loss of balance noted. Fall prevention goal met.”
Narrative notes are great for describing the flow of care in more detail, but you’ll still want to include evaluations to ensure all outcomes are documented.
For more on writing clear SOAP notes and Narrative Notes, check out our guide on How To write Nursing Notes
Why Different Formats Matter
Each format serves a different purpose. SOAP and SOAPIE are best for clear and concise documentation, while narrative notes allow for more detailed descriptions. Knowing how to use each format helps ensure your documentation is accurate and meets your facility’s requirements.
What to Do When a Goal Is Not Met
Not every goal will be achieved immediately, and that’s perfectly fine. When a goal isn’t met, it simply means you need to reassess and adjust the care plan. Here’s a simple process to follow when a goal isn’t met.
- Reassess the Patient
Check vital signs, labs, and observations to confirm what’s going on. Are there any new issues that need attention? - Review the Interventions
Were the interventions carried out as planned? Did they work? If not, consider why they didn’t achieve the desired outcome. - Adjust the Timeframe
Some goals take longer to achieve. If the patient is making progress but hasn’t fully met the goal, you might need to extend the timeframe. - Modify the Interventions
If the interventions aren’t working, it may be time to try a different approach. Consider adding or changing methods, or consulting with other healthcare professionals for additional ideas. - Update the Care Plan
Document any changes made to the care plan and share it with the team. Clear communication ensures everyone is on the same page.
Example:
Let’s say a patient’s goal was to ambulate 50 feet with a walker by the end of the shift, but they only managed 20 feet.
- Evaluation: “Patient ambulated 20 ft with walker and fatigue; goal not met.”
- Plan: “Extend timeframe to 72 hours, increase PT frequency, and encourage hourly mobility exercises.”
By updating the plan, you help ensure the patient continues to make progress toward their goal, even if the original timeline wasn’t met.
Conclusion
In nursing, evaluations are an essential tool for ensuring that patient care is effective and that goals are met. By following the evaluation process clearly and consistently, nurses can improve the quality of care, ensure patient safety, and foster better communication across teams.
As you continue to practice and refine your skills in writing nursing evaluations, you’ll become more confident in documenting patient progress and making informed decisions about care plans.
Frequently Asked Questions (FAQs)
What Nursing Action Reflects Evaluation?
In nursing, evaluation refers to the process of assessing how well the care you’ve provided worked. The nursing action that reflects evaluation includes:
- Monitoring patient progress based on the set goals.
- Assessing patient responses to interventions or treatments.
- Documenting the outcomes of care to compare what was expected with what actually happened.
These actions help you decide what changes might be needed and ensure that the care plan stays effective.
What Is Evaluation in a Nursing Care Plan?
Evaluation in a nursing care plan is the process of checking if the care goals were met. It’s the part where you assess the effectiveness of the care provided and decide if any adjustments are needed.
This step involves:
- Reviewing patient progress: Has the patient met the care goals?
- Measuring outcomes: Are the goals fully met, partially met, or not met?
- Adjusting the care plan: If necessary, the care plan is modified to ensure the patient gets the right care.
What Is Evaluation in the Nursing Process?
In the nursing process, evaluation is the final step that checks if the care plan worked. It answers whether the patient’s goals were achieved, and helps adjust the plan if the desired outcomes weren’t reached.
Evaluation in nursing is about:
- Comparing expected vs. actual outcomes: Did the plan achieve what was expected?
- Making adjustments: If the goal isn’t met, changes are made to improve patient care.
What Is Evaluation of Care in Nursing?
Evaluation of care in nursing is the process of reviewing whether the patient’s care goals were met. It’s a key step that helps ensure effective care and makes sure the nursing process is working as intended.
It involves:
- Assessing the patient’s response to treatments.
- Measuring the patient’s progress against the care goals.
- Making necessary changes to the care plan to improve outcomes.
How to Write Evaluation for a Nursing Care Plan?
Writing an evaluation for a nursing care plan involves documenting the progress made toward the patient’s goals. Here’s what you should include:
- Goal status: Was the goal met, partially met, or not met?
- Outcome data: Use measurable results to show what happened.
- Next steps: Based on the evaluation, what changes will be made to the care plan?
Example:
“09/30 0700: Patient reports pain 2/10 after medication; goal met. Plan: Continue oral analgesics and reassess every 8 hours.”
How to Write a Nursing Evaluation Statement?
To write a nursing evaluation statement, follow these steps:
- State the goal: What was the expected outcome?
- Describe the outcome: What happened during the evaluation?
- Document the next step: What changes or actions will happen next?
Example:
“09/30 1930: No falls reported; patient used call bell before ambulating. Goal met. Plan: Reinforce safety teaching and continue hourly rounds.”
