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Accurate documentation has a huge impact on a patient’s improvement in health recovery. Doing accurate and clear documentation is essential in nursing care. It is also in the clinical guidelines of nursing and is one of many responsibilities of nurses. Some nurses tend to disregard the guidelines of appropriate documentation and then, later on, regrets it. So if the Board summoned you, hire a nurse attorney for help in facing the Board.

There is an incident wherein an RN was employed as a Registered Nurse at a hospital in McAllen, Texas, and had been in that position for two (2) years.

It was on or about February 27, 2019, The RN failed to completely document the vital signs of a patient, per orders. Additionally, the RN inaccurately documented the NIH Stroke Scale (NIHSS) for the patient, throughout her shift. Specifically, the RN reported to the day nurse that the patient was uncooperative and she was unable to obtain a full NHISS. However, she had documented NIHSS assessments in the patient’s medical record for the entirety of her shift, which was unchanged from the patient’s NIHSS documented previously in the emergency room. The RN’s conduct resulted in an incomplete and inaccurate medical record and was likely to injure the patient from subsequent care decisions made without the benefit of accurate and reliable information.

In response, the RN states that she did document the vital signs as required. The patient’s vital signs were stable throughout the night. The vital signs were recorded and sent directly to EPIC and were available for review. All vital signs were available in the medical records. Regarding the NIHSS issue, the patient was severely obtunded, having received Benadryl, Haldol, and Ativan in the Emergency Room and she was uncooperative. At the beginning of her shift, she had advised the charge nurse she was not familiar with the NIHSS scale. The charge nurse did not assist her but instead told her to follow the emergency department’s reports. She also documented the NIHSS assessments to the best of her ability, based upon her understanding of the assessment tool and the scale. The RN documented in her nursing note that the patient was uncooperative. There were no instructions or scale definitions for her to review in the ICU. Further, the other nurses who cared for the patient failed to properly document and perform the NIHSS assessments. There was a lack of training and education by the nurse manager on how to properly perform NIHSS assessments.

The actions of the RN were grounds for violations. Her actions and the information that were submitted as evidence were the basis for the Boards decision. It is to take disciplinary action against the RN. This sanction given by the Board which is in accordance with the law can be avoided with the help of a nurse attorney.

Always remember that a nurse attorney can help you in any way they can. So, if 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.