Communication		The oral account of care and observations
Comprehensive care plan		Using the senses of sight, hearing, touch, and smell to collect information
Medical Record		A written guide giving direction for the resident's care; required by OBRA
Nursing care plan		A written guide about the person's care
Nursing process		Things a person tells you about that you cannot observe through your senses; symptoms
Objective Data		The method nurses use to plan and deliver nursing care; its five steps are assessment, nursing diagnosis, planning, implementation, and evaluation
Observation		A written or electronic account of a person's conditions and response to treatment and care; chart
Recording		The exchange of information - a message sent is received and correctly interpreted by the intended person
Reporting		The written account of care and observations; charting
Subjective Data		Information that is seen, heard, felt, or smelled by an observer, signs