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In the healthcare profession, patient records and the integrity of medical documentation are of paramount importance. Accurate and transparent records not only serve as the basis for patient care decisions but also uphold the ethical and legal standards that govern the medical profession. When healthcare professionals, like the RN described in this case, are alleged to have inappropriately accessed and manipulated electronic medical records, serious concerns arise regarding the accuracy of patient documentation and the potential for deception within the healthcare system. In situations like this, the role of a nurse attorney becomes crucial in addressing the legal and ethical ramifications. The nurse attorney can work diligently to protect the legal rights of the RN throughout any investigations, legal inquiries, or regulatory actions that may follow the incident.

At the time of the initial incident, she was employed as an RN at a hospital in Fort Worth, Texas, and had been in that position for two (2) years and ten (10) months.

On or about July 10, 2021, through July 18, 2021, while employed as an RN at a hospital in Fort Worth, Texas, RN inappropriately used a physician’s electronic medical record identification login to document treatment plans, approve chemotherapy treatments, e-prescribe medication, and sign and submit prescriptions to the pharmacy for seventeen (17) patients, at the direction of the physician during dates and times when the physician was out of the office. RN’s conduct resulted in inaccurate medical records and was deceptive to providers, the facility, and other staff members who utilize the medical record to make treatment decisions.

In response, RN states that she recognizes her mistake in not fully complying with the hospital’s policy regarding the use of Electronic Health Record (EHR) logins. RN states that for nearly four (4) years she worked with the above-mentioned physician side-by-side, and when the physician was out of office the physician remained in very close contact with nursing staff by communicating with nurses several times a day through telephone, email, and text message. RN states that between July 10th and 14th, 2021, and July 18, 2021, while the physician was out of town, RN’s work regarding patients was completely at the physician’s direction. RN adds that her completion of treatment care plans was strictly clerical with no medical judgment. Regarding prescribing medication, RN states that the hospital uses an e-prescribing application that her and the physician worked collaboratively on to prepare prescriptions. RN states that the physician decided what medications and dosages to prescribe, and RN completed the task by inputting information into the system. Regarding falsification of treatment plan and medication orders, RN states that all documentation at issue was made with the knowledge or and at the direction of the physician. RN states that she did use the EHR   login of the physician to accomplish the tasks assigned to her by the physician in some instances.

The above actions constitute 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)(D) and 22 TEX. ADMIN. CODE §217.12(1)(A), (1)(C), (6)(H)&(10)(B).

However, without valid evidence to defend her side of the story, the RN lost the case. Furthermore, the RN failed to hire a Texas nurse attorney to help her with her case. Because of this, the Texas Board of Nursing disciplined the RN’s license.

Do not be stressed or anxious if you find yourself in a similar situation as that of the RN mentioned above. All you need to do is to find the right RN/LVN license attorney who can help you in the case. Equip yourself with the knowledge and expertise you need for a successful outcome by consulting a knowledgeable and experienced Texas RN/LVN 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.