# Documentation --- **Documentation** is a part of the [[nursing process]] where we enter stuff into the chart. Painting a picture with as few words as possible. it's [[the law]], the patient's chart is a *legal document*. communication between teams. records (i.e. [[MAR]])-safety! monitoring trends. supports continuity of care. QI. risk management. reimbursement. [[collaborative pathway]] also important for protecting from [[the law|litigation]]. everyone wants to sue you. [[assessment documentation]] ## Types of Notes SOAP - Subjective, Objective, Assessment, Plan (?) PIE - problem, intervention, evaluation ___