1. preparation tool
1.1. stationery
12. Format CPI assessment - CPS
2. working procedures
- Record the results of nursing assessment / data collection in nursing history format (CPI)
- Record nursing diagnosis or collaborative problem has been formulated in the format of CP2 2.3. Record nursing plan of action has been determined in the planning stage in CP3 format
- Record nursing actions that have been done in the format CP4
- Record results achieved in the evaluation phase of nursing progress notes format or CPS
3. documenting actions
- The timing of the nursing documentation needs oxygen
- The documentation clearly legible note
- Documentation signed and the full name and clearly
