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Accurate and detailed documentation of patient encounters is a crucial responsibility for nurses, as it forms the foundation of healthcare records and aids in providing effective and continuous patient care. However, instances of inappropriate documentation can raise significant concerns about the quality and integrity of patient records. Such discrepancies in documentation can have serious implications for patient care and may lead to questions about the RN’s conduct and adherence to professional standards. When faced with allegations related to improper documentation, seeking the guidance of a nurse attorney is essential to navigate the legal complexities, protect the RN’s rights, and ensure a fair and thorough investigation into the matter.

At the time of the initial incident, she was licensed as an RN at a medical facility in Laredo, Texas, and had been in that position for three (3) months.

On or about April 15, 2020, while working as an RN at a medical facility in Laredo, Texas, RN inappropriately documented her patient encounter for the patient, including a physical exam. Later, RN reported that she did not have time to see the patient. RN’s conduct also created an incorrect entry in the medical record, upon which other caregivers could have relied for subsequent care of the patient.

In response, RN reports she never intended to falsify medical records; all the information in the note was obtained from the nurse through a verbal report. RN reports she intended to transcribe a phone encounter and it was never meant to be placed in the chart, nor was the encounter billed.

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)(B),(1)(D)&(4)(A) and 22 TEX. ADMIN. CODE §217.12 (1)(A),(1)(B),(1)(C),(6)(A)&(4).

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 16 years and represented over 300 nurses before the Texas BON. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679.