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10 Cards in this Set
- Front
- Back
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Chart/Medical Record |
Written or electronic account of a person's condition and response to treatment and care |
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Communication |
The exchange or information a message sent is received and correctly interpreted by the intended person |
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Comprehensive care plan |
A written guide giving direction for the residents care |
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Nursing care plan |
Written guide about the persons care |
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Nursing Process |
Method nurses use to plan and deliver nursing care; its five steps are assessment, nursing diagnosis, planning, implementation, and evlutation |
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Objective Data/ Signs |
Information that is seen, heard, felt, or smelled by an observer |
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Observation |
Using senses of sight, hearing, touch, and smell to collect information |
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Recording |
Written account of care and observations |
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Reporting |
The oral account of care and observations |
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Subjective data/symptoms |
Things a person tells you about; that you cannot observe through senses |
