Evaluation
What to know
Evaluation compares the patient's current status with the goals set during planning. It requires reassessment, trend analysis, and documentation of the response to intervention. Know process measures (was the intervention done correctly?) versus outcome measures (did the patient improve?). Evaluation drives revision: continue, modify, or discontinue the plan. Quality improvement uses data, root-cause analysis, and benchmarks; individual evaluation uses objective criteria such as pain rating, oxygen saturation, intake/output, glucose, or mobility level.
Traps
- Confusing evaluation with the initial assessment.
- Assuming "stable" means the goal was met.
- Evaluating too early, before the intervention can work, or too late to prevent harm.
- Ignoring the patient's own report of improvement or decline.
- Documenting "goal met" without evidence.
Worked example
A patient receives IV opioid for pain 8/10 with a goal of 3/10 or less. Reassess at the policy interval (commonly 30-60 minutes for IV opioids) and document pain score, sedation, respiratory rate, and function. If pain is unchanged and sedation is increasing, the goal is not met; hold further opioid, assess, and escalate. Rule: evaluate against the same objective criteria you set in planning, and let the response determine the next action.