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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, and 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, the 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 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 saw the patient on March 5, 2021. RN’s conduct created an inaccurate medical record.

In response, the RN stated that the March 1, 2021 visit was rescheduled due to factors beyond her control. When the 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 the 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).

After the incident in question, the Texas Board of Nursing (BON) conducted a thorough investigation and summoned the RN involved. Unfortunately, the RN was found guilty of the allegations. However, if the nurse had hired a Nurse Attorney, a legal professional who specializes in nursing cases, they could have provided valuable assistance in defending against the accusations. Nurses facing accusations should consider hiring a Nurse Attorney as they have the expertise and knowledge to handle different kinds of allegations. It’s essential to have the right support and guidance to ensure the best possible outcome during such challenging situations.

If you have received a letter from the Texas Board of Nursing regarding a case or complaint filed against you, it is crucial to take immediate action. With almost two decades of experience, Texas Nurse Attorney Yong J. An has represented numerous nursing license cases successfully.  Do not hesitate to contact him 24/7 for a private case evaluation by calling or texting him at (832) 428-5679.