relate to information that you obtain directly

relate to information that you cannot detect with one of your five senses

sometimes reffered to as charting

legal document where information about the person's currect condition

provides standard information about the person, including the person's name, address, date of birth and age

the medical record contains dictated and typed medical history from the person's doctor

completed by the nurse at the time of the person's admission to the facility

used by the doctor to communicate to the other member of the health care team

the medication ordered for the patient or resident are listed here, along with the dosage

The doctor uses this form to record his notes and observations about the person's progress

the nurse uses this form to document the person's complaints and actions by the nursing staff

this is where information that is gathered routinely

laboratory reports, radiology reports and reports related to other diagnostic tests or therapeutic treatments

a card file, containing condesed versions if each patients or residents medical record

collection of techniques that prioritize the physical mental and emotional well being of the patient

the ideas, customs and social behavior of a particular people or society

the ability to understand and interact effectively

usually indicates cultural heritage, the experience shared by people who have a common ancestral origin

a category of human kind that shares certain physical traits

the understanding that our own culture beliefs from one individual and group to the next

something that you notice about the patient or resident