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The accuracy and integrity of medical records stand as the cornerstones of responsible patient care and ethical practice. Proper documentation not only ensures that patients receive the care they need but also forms the basis for critical healthcare decisions. However, when situations arise where medical records are inaccurately documented, it raises concerns about transparency and the potential consequences for patient care. In situations like this, the involvement of a nurse attorney is instrumental in addressing the legal and ethical dimensions of the matter. A nurse attorney possesses a deep understanding of healthcare laws, regulations, and the significance of maintaining accurate and truthful medical records.

At the time of the initial incident, she was employed as an RN with a home health care provider in Frisco, Texas, and had been in that position for two (2) years and five (5) months.

On or about March 1, 2021, through March 5, 2021, while employed as an RN with a home health care provider in Frisco, Texas, RN incorrectly documented in the medical record of the patient that she completed a Skilled Nursing Visit for March 1, 2021, when the visit was actually performed on March 5, 2021. In addition, RN had the patient sign the timesheet which incorrectly dated the visit as March 1, 2021, when she actually saw the patient on March 5, 2021. RN’s conduct created an inaccurate medical record.

In response, RN states the March 1, 2021 visit was rescheduled due to factors beyond her control. When RN made the visit on March 5, 2021, she dated it as March 1, 2021, so it would be the correct frequency of visits as ordered by physician and it would not be considered a missed visit under the conditions of Medicare participation.

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)(A)&(6)(H).

The evidence against the RN was strong. At the same time, she was not able to properly defend her case in court. As a result, her nursing license was placed under disciplinary action.

Avoid the similar thing from happening on your end. Make sure to find the right defense attorney in case a complaint will be filed against you before the Texas Board of Nursing (BON). For more details or for a confidential consultation regarding accusations, it’s best to contact an experienced Texas nurse attorney. Texas Nurse Attorney Yong J. An is an experienced nurse attorney who represented more than 500 nurse cases for RNs and LVNs for the past 17 years. You can call him at (832) 428-5679 to get started or to inquire for more information regarding nursing license case defenses.