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Nursing Documentation Review Checklist

Comagine Health

Documentation is essential to providing quality care and meeting the resident’s needs. Ensuring that the care provided and the resident’s response to that care is accurately reflected in the documentation informs ongoing care, reduces risk for liability and supports the best outcomes.

Use this checklist as part of a peer review of clinical documentation to assess completeness and quality of information included in the notes. This checklist can also be used to build competency with documentation.