is the oral account of care done and observations, noted, given to other members of health care team
reporting
is a legal document that organizes all the information about care of a single resident in one document and allows each discipline involved in the care to know what all disciplines are doing
medical record
the exchange of information, either verbally or in written form, between and among members of the health care team
communicating with the health care team
information told to nurse aide
subjection data
observations using the senses
objective data
is the written account of care done by the nurse aide and observations noted, in pen and paper form or electronic form
recording