As an auditor, I review charts from facilites across the US. I am amazed at what is and isn't documented and I frequently have commented how in earth would some of the things I see stand up in court. Even with EMR, there will be pages of documents left blank or marked as "not assessed" so the clinician can get to the last entry field to chart on the patient with significant dementia "reminded patient to use call bell". It also important to realize that documentation is also used to support justification of billing, and definitely in that area, if it isn't documented, it didn't happen; and if it didn't happen it won't be reimbursed.