| A | B |
|---|
| communication | The exchange of information—a message sent is received and correctly interpreted by the intended person |
| comprehensive care plan | A written guide giving direction for the resident's care; required by OBRA |
| medical record/chart | A written or electronic account of a person's condition and response to treatment and care |
| nursing care plan | A written guide about the person's care; care plan |
| nursing process | The method nurses use to plan and deliver nursing care; its five steps are assessment, nursing diagnosis, planning, implementation, and evaluation |
| objective data/signs | Information that is seen, heard, felt, or smelled by an observer |
| observation | Using the senses of sight, hearing, touch, and smell to collect information |
| recording | The written account of care and observations; charting |
| reporting | The oral account of care and observations |
| subjective data/symptoms | Things a person tells you about that you cannot observe through your senses |
