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Failure in documenting a complete assessment of a patient could become a problem to the patient’s treatment and a problem also for the RN’s part, as this could be the reason for her/his being put into disciplinary action. But always remember that a Texas nurse attorney can help you go through accusation and complaint cases.

At the time of the initial incident, an RN was employed as a Registered Nurse at a hospital in Pharr, Texas, and had been in that position for ten (10) months.

An incident happened on or about August 24, 2019, through August 25, 2019, an RN failed to document a complete assessment of a patient. The RN’s conduct resulted in inaccurate, incomplete medical records, and could have injured the patient in that subsequent caregivers would rely on his documentation to provide further patient care.

In regards to the incident, the RN states when he arrived for the 19:00 shift, the patient was receiving his 3rd-liter bolus and an intravenous piggyback (IVPB) of Rocephin. In addition, the physician ordered an infusion of Magnesium 3g, so the RN started a 2nd intravenous (IV) site. The RN states he checked on the patient frequently because he had a fever and his initial Lactic acid was elevated. On Sunday, the physician ordered two more boluses so the RN questioned the physician about continued boluses — in response, the doctor decreased the rate to 150ml/hr. In addition, the RN suggested labs in order to track the patient’s status but the physician stated he would reassess the patient and check labs in the morning. The RN states he did not refuse to implement the physician’s orders because there was a concern for severe dehydration as evidenced by the elevated creatinine and multiple bowel movements reported by the patient during the shift. Before 01:00, the RN reported the patient’s episode of nausea and abdominal discomfort to the physician who ordered 4mg IV Morphine and a Phenergan IV. The RN wanted to avoid further excess fluids, so he suggested the Phenergan as a 6.25mg intravenous push (IVP) and the physician was agreeable. Medications were effective and the patient’s only further complaint was continued bowel movements. The RN states he continued to assess the patient’s temperature which normalized. The RN states the facility’s point-click documentation system only allowed one complete assessment per visit.

As a result, due to the incident; the Texas Board of Nursing had placed the RN into disciplinary action. This had to happen as the RN had failed to hire a Texas nurse attorney as a legal counsel before facing the Board. This could have led to a different outcome if only the RN consulted and hire a Texas nurse attorney.

Regarding a case or complaint filed on you, you should hire a nurse attorney immediately before it’s too late. Texas nurse attorney Yong J. An is one of those dedicated nurse lawyers who have helped various nurses in their cases since 2006. You may contact him 24/7 at (832) 428-5679 for more information or if you want to schedule a private consultation.