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Maintaining accuracy and precision in medical documentation is a fundamental aspect of nursing practice, ensuring the delivery of safe and effective patient care. In instances where nurses face allegations or legal concerns related to inaccurate medical documentation and potential risks to patient safety, a nurse attorney can provide crucial assistance. A nurse attorney specializes in navigating the legal complexities surrounding such incidents, conducting a thorough evaluation of the situation.

At the time of the incident, she was employed as an RN at a hospital in Killeen, Texas, and had been in that position for two (2) years and three (3) months.

On or about December 7, 2021, while employed as an RN at a hospital in Killeen, Texas, RN documented administration of both midodrine, medication to raise blood pressure, and hydralazine, medication to lower blood pressure, in the medical record of a patient at the same time. The midodrine had been discontinued due to an elevated blood pressure reading of 181/81. Additionally, RN failed to timely reassess the patient’s blood pressure after administration of the hydralazine, to determine effectiveness. The patient’s blood pressure remained elevated at 183/78 two hours later. RN’s conduct resulted in an inaccurate medical record and exposed the patient to a risk of harm from clinical care decisions based on incomplete assessment information.

Without consulting with a nurse attorney, RN responded to the above incident and denied that she documented that both medications were administered. RN entered a note into the patient’s charts that did not save. The next day, in less than 24 hours, when RN realized that the note did not save, she entered additional notes stating that both medications were not administered. RN believes this created an accurate patient record. Moreover, the patient’s blood pressure had been fluctuating for four days but was being correctly monitored. The patient care technician that RN assigned to assess the patient’s vital signs did as required.

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

As a result, the Texas Board of Nursing decided to place her RN license under disciplinary action. It’s too bad that she failed to hire a nurse attorney for assistance, knowing that she had every reason to defend herself in the first place. Her defense would have gotten better if she sought legal consultation from a Texas nurse attorney as well.

So, if you’re facing a complaint from the Board, it’s best to seek legal advice first. Texas Nurse Attorney Yong J. An is willing to assist every nurse in need of immediate help for nurse licensing cases. He is an experienced nurse attorney for various licensing cases for the past 17 years and represented over 500 nurses before the Texas BON. To contact him, please dial (832)-428-5679 for a confidential consultation or for more inquiries.