In nursing care, a complete and accurate medical record, in a timely manner, brings positive outcomes on the health improvement of a patient. Failure to timely document with incorrect and inaccurate health information of a patient means poor outcome. This shows that accurate documentation of health information has a huge impact on a patient’s recovery. But if an RN, improperly executes such a task in nursing care, the Board may put the RN into disciplinary action with suspension or revocation of license. If this happens, it is better to seek help from a nurse attorney.

An incident happened on or about November 14, 2018, a nurse was employed as a Registered Nurse at a hospital in Laredo, Texas. At the time of the incident, the RN was caring for a patient. The RN failed to timely document the patient’s temperature in the medical record throughout her shift; failed to correctly/accurately document. The patient’s urine output; and failed to completely document the patient’s intravenous intake, and feeding tube maintenance. The RN’s conduct resulted in an inaccurate medical record and was likely to injure the patient in that subsequent caregivers would not have reliable information on which to base their care decisions.

In response to the incident, the RN states that there was an issue with the temperature probe which she reported. The patient’s temperature at 2000 on 11/14/18 was normal and she took an axillary temperature at 0400 which was normal. The RN performed a full assessment on the patient which had not been done by preceding nurses, charted vital signs, and all medications were given. The RN did monitor the patient’s fluids intake/output. It was a very busy night. There was a code and a rapid response and she assisted other nurses with their emergencies and she also admitted a very ill patient. Due to the busy pace of the shift, she was not able to do hourly intake and output so they were instead documented at the end of the shift.

Due to the incident, her actions put her in a bad situation. The Boards have put her into disciplinary action. The evidence submitted to the Board was the basis of the sanction laid against the RN. This outcome can be changed if only she hired a nurse attorney for the defense. Failure in hiring someone who can help you at times of trouble is the end of your RN career and your RN license.

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