Title: Describe the documents that are used by the healthcare team to communicate information and needs of a client/resident/patient.
Course: Nurse Aide I Condensed (14051-I-A) > Section: Communicating in the Healthcare Environment

Description includes

- client/resident/patient medical record (chart)
  - admission sheet
  - health history
  - examination results
  - physician’s orders
  - physician’s progress notes
  - health team notes
  - lab test results
  - special consents
- hard copy of health records or electronic health record (EHR)—condensed version of medical record
- Minimum Data Set (MDS)
  - assessment tool
  - provides structured, standardized approach to care
  - helps identify a client/resident/patient healthcare problems
- person-centered care plan
  - outlines care that the healthcare team must perform to assist a client/resident/patient to attain optimal level of functioning
  - written by a nurse (RN or LPN)
  - CNA contributes by observing and reporting signs and symptoms.

Refer to Unit II in Nurse Aide Curriculum, Virginia Board of Nursing, Virginia Department of Health Professions, 2018.

Process/Skill Questions:

- What documentation should a CNA review before giving care?
- Why is it important to follow the care plan?
- What documents are available to a CNA for viewing and documentation?
- Why is it important to document care in a healthcare setting?
- What documentation formats might a CNA encounter?