“You’re a newspaper reporter. Who, what, where, when, why, and how.”
That’s how Margo Kunze, RN, CDP, a legal nurse consultant and author, describes the importance of healthcare documentation. In this episode of Nurse to Nurse, Margo joins hosts Mandy Curtis, RN and Gwen Wilburn, RN to talk about the risks of poor (or even non-existent) documentation. She also explains how nurses can protect themselves while improving the lives of their patients.
In this episode, you’ll hear about:
- Capturing subtle changes in documentation to anticipate issues and improve care
- The risks of charting by exception, which can miss early indicators of serious issues
- Why detailed, transparent charting protects residents and providers legally
- Why to avoid abbreviations, so documentation stays clear and useful
- Legal cases that show why documentation matters
Whether you’re at the bedside or leading a team, this conversation is a good reminder that a clear chart is care and protection in one.