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Chapter 4

Communication The oral account of care and observations
Comprehensive care plan Using the senses of sight, hearing, touch, and smell to collect information
Medical Record A written guide giving direction for the resident's care; required by OBRA
Nursing care plan A written guide about the person's care
Nursing process Things a person tells you about that you cannot observe through your senses; symptoms
Objective Data The method nurses use to plan and deliver nursing care; its five steps are assessment, nursing diagnosis, planning, implementation, and evaluation
Observation A written or electronic account of a person's conditions and response to treatment and care; chart
Recording The exchange of information - a message sent is received and correctly interpreted by the intended person
Reporting The written account of care and observations; charting
Subjective Data Information that is seen, heard, felt, or smelled by an observer, signs

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