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The accuracy and thoroughness of medical documentation are pillars of responsible patient care and ethical practice. However, when situations arise where medical records are inaccurately documented, it raises concerns about transparency and the potential consequences for patient care. In such instances, the involvement of a nurse attorney is vital for addressing the legal and ethical dimensions surrounding accurate medical documentation. A nurse attorney’s expertise ensures adherence to healthcare laws, regulations, and the commitment to maintaining truthful and precise medical records.

At the time of the initial incident, she was employed as an RN at a healthcare facility in Dallas, Texas, and had been in that position for four (4) years and one (1) month.

On or about April 24, 2021, while employed as an RN at a healthcare facility in Dallas, Texas, RN documented detailed and focused assessments for a patient, to include assessments for pain, fall risk, medication history, dysphagia screening, NIH stroke scale, and patient education, even though she did not enter the patient’s room. Furthermore, RN documented the patient, who was Spanish speaking, verbalized understanding of the education. RN’s conduct was deceptive, resulted in an inaccurate medical record, and was likely to injure the patient from possibly undetected changes of condition.

The above action constitutes grounds for disciplinary action in accordance with Section 301.452(b)(10)&(13) Texas Occupations Code, and is a violation of 22 TEX ADMIN. CODE §217.11(1)(A),(1)(B),(1)(D),(1)(M)&(3) and 22 TEX. ADMIN. CODE §217.12 (1)(A),(1)(B),(1)(C),(4)&(6)(A).

The Texas Board of Nursing then subjected the RN’s license to disciplinary action. The accusation would have been defended by an experienced and skilled nurse attorney, had the RN hired one. Hiring a nurse attorney for defense is applicable for any kind of accusation laid against an RN or LVN.

Always remember that anyone can file a complaint against an RN/LVN with the state board for any reason. When this happens, all complaints need to be taken seriously no matter how trivial or unfounded they may appear. A nurse attorney is someone who can help you defend your license when the state board summons you. Equip yourself with the knowledge and expertise you need for a successful outcome by consulting a knowledgeable and experienced Texas RN license attorney. Texas Nurse Attorney Yong J. An is an experienced nurse attorney for various licensing cases for the past 17 years and represented over 500 nurses before the Texas BON. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679.