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Communication with the Health Care Team
the exchange of information, either verbally or in written form, between and among members of the health care team
HIPAA (Health Insurance Portability and Accountability Act)
law that protects the privacy and security of a person’s health information
Medical Record
a legal document that organizes all the information about care of a single resident in one document and allows each discipline involved in the care to know what all disciplines are doing
Objective Data
observations using the senses
Recording
the written/electronic documentation of care and observations by the health care team
Reporting
the oral account of care done and observations noted
informing other members of the health care team
Subjective Data
information collected through communication
what is said