Medical Records should be documented with complete and accurate information of patients along with correct administered medications. Tampering or altering medical records is illegal and is a crime punishable with fines and jail time. By doing such, can mislead and can cause harm to patients. But if you are dealing with such accusations or complaints, it is best to seek help from a nurse attorney.

At the time of the initial incident, an RN was employed as a Registered Nurse at a hospital in Georgetown, Texas, and had been in that position for five (5) months.

It was on or about December 9, 2018, when the RN failed to accurately assess and/or inaccurately documented the neurological status of a patient in that she documented a score of fifteen (15) on the Glasgow Coma Scale which is inconsistent with her documented score of twenty-eight (28) on the Health Stroke Scale, which indicates a severe stroke. The RN’s conduct created an inaccurate medical record and was likely to injure the patient in that subsequent caregivers would rely on her documentation to provide further patient care.

In response, the RN states that she was still learning and mastering the Apollo charting software. The RN admits that she should have documented GCS 12 instead of 15, and that she might have clicked in error the orientation section of the GCS assessment, but that her intention was to document that the patient was confused. The RN states that she did document that the patient was confused in the nurse’s notes. The RN states that no harm came to the patient as a result of this.

As a conclusion to the misconduct and actions made by the RN, the Texas Board of Nursing has come to the decision that the RN shall be subjected to discipline. The RN failed to hire a nurse attorney to fully defend her case and had led to this decision of the Board.

Do you have questions about the Texas Board of Nursing disciplinary process? Contact The Law Office of Nurse Attorney Yong J. An for a confidential consultation by calling or texting 24/7 at (832) 428-5679 and ask for attorney Yong.