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chart / medical record
a written or electronic account of a person's condition and response to treatment and care
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communication
the exchange of 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 resident's care; required by OBRA
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nursing care plan
a written guide about the person's care; care plan
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nursing process
the method nurses use to plan and deliver nursing care; its five steps are assessment, nursing diagnosis, planning, implantation, and evaluation
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objection data / signs
information that is seen, heard, felt, or smelled by an observer; signs
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observation
using the senses of sight, hearing, touch, and smell to collect information
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recording
the written account of care and observations; charting
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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 your senses; symptoms
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NANDA-I
North American Nursing Diagnosis Association International
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OBRA
Omnibus Budget Reconciliation Act of 1987
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PDA
Personal digital assistant
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PHI
Protected health information
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RAPs
Resident Assessment Protocols
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admission sheet
it has the person's identifying information
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health history
completed by the nurse
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graphic sheet
used to record measurements and observations made daily, every shift, or 3 to 4 times a day
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progress notes
used to describe observations, the care given, the person's response and progress
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flow sheets
used to record frequent measurements or observations- person's every day activities
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ADL
Activites Daily Living
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