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8 Cards in this Set
- Front
- Back
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Chart |
The chart contains the healthcare plan, the physicians orders, and all the health info on one particular resident. It is legal document and must be maintained properly |
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Chronological |
Written in the order in which the events occurred |
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Documentation |
Written info in the medical record |
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Electronic medical record EMR |
Digital version of a patients entire medical history from a particular practice |
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Flow sheet |
A graphic chart that is commonly used in long term care to record resident info over time |
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Nursing care plan Resident care plan |
The complete plan of care for each resident |
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Objective observation |
Observation based on facts you can see, hear, or measure |
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Subjective observation |
Observation based on what the resident tells you |
