by | Oct 2, 2023

Complaints regarding the failure of documenting accurate and complete medical records are one of the cases that a nurse attorney can resolve. These professionals can guarantee their clients that any complaints about them can be denied by the Texas Board of Nursing once you hire them for assistance.

At the time of the incident, an RN was employed as a Registered Nurse at a hospital in Corsicana, Texas, and had been in that position for two (2) years.

On or about October 29, 2019, while employed as a Registered Nurse and assigned to a patient, the RN failed to clarify the Emergency Department’s physician’s order, which called for neuro checks and blood glucose checks to be completed every four (4) hours, with the day shift physician assigned to the floor. Further, the RN completed one (1) neuro check and one (1) blood glucose check but failed to complete additional checks during her shift. At the end of her shift, the RN told the oncoming nurse that she forgot about the neuro checks and blood glucose checks. The RN’s conduct could have contributed to patient injury and could have resulted in non-efficacious treatment.

On or about October 29, 2019, while employed as a Registered Nurse, the RN failed to document an attempted neuro check and blood glucose check, that occurred at noon, in a timely manner. The RN instead documented the neuro check and blood glucose check at the end of her shift, after 1900, and inaccurately documented the checks as having taken place at 1740. The RN’s conduct resulted in an inaccurate medical record.

In response, the RN states that because the patient moved from one unit to another and the patient’s diagnosis changed from one point in time to another, that the MD orders that were still in effect during the RN’s shift were not applicable. The RN further states that she attempted to perform the ordered checks at one point in time but was refused by the patient. The RN states that upon advising the physician, no additional orders were given nor concern expressed. The RN states she takes accountability for her charting, and further states it was not her intention to cover-up something, but to complete documentation for the day. 

As a result of what happened, the RN is facing disciplinary action due to her misconduct. However, she failed to hire an experienced nurse attorney for proper assistance, causing her to undergo such procedures.

Losing your LVN or RN license can compromise your career. However, a skilled nurse attorney can greatly help you in major cases such as this. For assistance regarding your nurse license case, it’s best to contact Nurse Attorney Yong J. An by contacting him at (832) 428-5679.

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