I think documentation is very important and in psy a lot of it is observation, it is important to d cument the patients behavior and effects of medication, or changes in vital signs or behavior in gerneral . Be careful do not diagnois ,just changes and observations, i think nurses are documenting to little,if there is no change then the note is very genreral, i amake it a habbit if i have to prn somebody i do a nsg note as to why, not just the prn note, this help the doctor change the medications to fit what i have described if i didn't document i would never interact with my docotrs due to working night shift and evening shift. there is no book, just remeber if its not documented it did not haappen, and when a chart goes tocourt years after an incident accurs you will not remember