This list is not intended to be all inclusive, but rather a site to initiate a search for literature from a variety of sources for nurses wishing to improve their documentation. Documenting an adverse incident. Write it down, for everyone's sake. Charting by exception. Use of computer-based records, completeness of documentation, and appropriateness of documenting clinical decisions.
Nurses are accountable for their records.
Using continuous improvement to obtain and document informed consent. Documentation and informed consent. Allan, Jennifer, and Englebright, Jane. Using Clinical Information Systems to Manage and Improve Care. Thorough documentation of patient care may prevent legal wranglings.