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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. However, 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, he was employed as an RN at a hospital in Allen, Texas, and had been in that position for six (6) months.

On or about September 16, 2019, while employed as an RN at a hospital in Allen, Texas, RN failed to accurately and/or completely document the number of attempts and the amount of difficulty experienced while accessing the Port-a-Cath for a patient who required intravenous access. Additionally, RN failed to activate the chain of command when the patient refused a peripheral intravenous site and requested to speak with the owner/manager to have another staff member access her port. Later, RN stated to the Chief Nursing Officer that he did not call for assistance because he felt there was no reason. Furthermore, RN failed to adhere to the facility’s policy when accessing a port-a-Cath, which was assessed as having redness or swelling and the patient complaining of pain. RN’s conduct created an inaccurate medical record and could have deprived subsequent caregivers of vital information on which to base further nursing care and interventions.

Another incident happened on or about October 1, 2019, while employed as an RN at a hospital in Allen, Texas, RN failed to completely and accurately document care given to the above mentioned patient, such that he requested a change to the original medical record without clarifying how to properly do so. As a result, the staff member believed RN asked him to delete the original medical record. RN’s conduct created confusion and could have resulted in the destruction of a medical record.

In response, RN states he assessed the catheter site and observed that it appeared slanted with slight swelling on the right side, but there was no redness or tenderness. RN states he reported this to the attending physician, who instructed him to attempt to access the port-a-cath. RN states he did as instructed and in fact was successful in one attempt. RN states when interviewed by a member of the facility’s management team, his reporting of the slanted port-a-Cath was mistaken as an indication that he had experienced difficulty in accessing the catheter when in fact, he was merely reporting the slanted port-a-Cath to the physician as he believed he was required to do. RN denies asking the Emergency Room front desk staff member to remove a part of the medical record previously recorded from September 16, 2019 for the patient.

The above actions constitute grounds for disciplinary action in accordance with Section 301.452(b)(13), Texas Occupations Code, and is a violation of 22 TEX. ADMIN. CODE §217.11(1)(A),(1)(B),(1)(C),(1)(D)&(1)(P).

As a result, the Texas Board of Nursing decided to place his RN license under disciplinary action. It’s too bad that he failed to hire a nurse attorney for assistance, knowing that he had every reason to defend himself in the first place. His defense would have gotten better if he sought legal consultation from a Texas nurse attorney as well.

So, if you’re facing a complaint from the Board, it’s best to seek legal advice first. Texas Nurse Attorney Yong J. An is willing to assist every nurse in need of immediate help for nurse licensing cases. He is an experienced nurse attorney for various licensing cases for the past 16 years and represented over 300 nurses before the Texas BON. To contact him, please dial (832)-428-5679 for a confidential consultation or for more inquiries.