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Maintaining accurate and comprehensive medical records is a fundamental aspect of nursing practice, especially when caring for pregnant patients. Proper documentation ensures the continuity of care, assists in monitoring patient progress, and supports sound decision-making by healthcare providers. However, lapses in recording essential information can lead to significant implications for both the patient and the nurse involved. Such discrepancies in documenting crucial information may have contributed to an untimely birth and could raise concerns about patient safety and the nurse’s conduct. When confronted with allegations related to inadequate documentation and potential impacts on patient care, seeking the guidance of a nurse attorney is imperative 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 employed as an RN at a healthcare facility in Killeen, Texas, and had been in that position for thirteen (13) years and one (1) month.

On or about September 12, 2020, through March 10, 2021, while employed as an RN at a healthcare facility in Killeen, Texas, RN failed to accurately document sonogram dates in the medical record of a pregnant patient and failed to correctly measure fundal height. Subsequently, there was a size/date discrepancy that remained unaddressed, and the infant was delivered preterm at 32 weeks gestation, instead of what medical staff believed to be 41 weeks gestation. RN’s conduct resulted in an inaccurate medical record and exposed the patient and infant to a risk of harm from complications of a preterm delivery.

In response, RN states that she failed to accurately document sonogram results but is not clear how this occurred. RN states that she recorded the wrong date on the patient’s chart of the sonogram report, though she always uses a measurement tape per protocol to have accurate size dates. RN states that afterwards, she changed her practice to check sonogram results repeatedly and made sure to chart everything on each visit accurately. RN adds that she never failed to identify discrepancies in fundal heights before or failed to consult with other providers to double check size if needed.

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

However, without enough evidence to prove she’s not guilty, the RN lost the case. This is the reason why the Texas Board of Nursing placed her RN license under disciplinary action.

If you ever undergo cases such as this, it’s best to seek the assistance of a good nurse attorney as it could make the case better in your favor. Be sure to find a nurse attorney who is experienced and knowledgeable in several nurse cases to ensure the best assistance possible. 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 16 years and represented over 300 nurses before the Texas BON. To contact him, please dial (832) 428-5679 for a confidential consultation or for more inquiries.