Title: Describe the documents that are used by the health care team to communicate information and needs of the resident.
Course: Nurse Aide (14051) > Section: Unit II: Communication and Interpersonal Skills

Description should include the

- resident’s 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 that provides structured, standardized approach to care and helps identify resident health care problems
- person-centered care plan – outlines care that the health care team must perform to assist the resident to attain optimal level of functioning; written by the RN or LPN, with contributions from the nurse aide.