Description includes

client 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 healthcare problems
person-centered care plan
- outlines care that the healthcare team must perform to assist a client 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, 2023.

Process/Skill Questions: