Maintaining ethical standards and accurate documentation within the healthcare industry is paramount to upholding the trust and integrity of patient care. Healthcare professionals are expected to adhere to strict guidelines when it comes to the creation and alteration of medical documents, particularly those involving assessments and evaluations conducted by physicians. Any breach of this trust can lead to serious repercussions not only for the individuals involved but for the reputation of the entire healthcare system. Such actions highlight the significance of transparency and accuracy in documenting medical assessments and evaluations, as well as the necessity of maintaining open and honest communication among healthcare professionals. When confronted with allegations involving the integrity of medical records, seeking legal guidance of a nurse attorney becomes crucial to navigate the complexities of the situation and ensure a fair and equitable resolution.
At the time of the initial incident, he was employed as an RN with a behavioral healthcare services provider in Abilene, Texas, and had been in that position for two (2) years and one (1) month.
On or about August 18, 2020, while employed as an RN with a behavioral healthcare services provider in Abilene, Texas, RN added the admitting psychiatrist’s signature on an unsigned version of a psychiatric evaluation without the physician’s knowledge or consent. RN’s conduct resulted in an inaccurate medical record.
In response, RN states that on August 18, 2020, RN was working his usual shift of 0730-1930 in the facility’s Crisis Treatment Center (CTC), in triage. Patients would enter the CTC, be triaged, and, if appropriate, be admitted to the residential unit (CRU), when all documents for admission were completed. The patient arrived at CTC at approximately 0955. RN performed the patient’s COVID testing per protocol and then he did his initial assessment from 1007-1022. After that, the patient was seen by the caseworker. The facility physician then evaluated the patient remotely through telemed, finished entering her evaluation/orders in the computer in which she admitted the patient to the CRU (inpatient unit). RN states that she and RN had a telephone conversation in which RN thought that he was given a verbal order to sign the evaluation, because, per the facility’s protocol, a patient could not be transferred from CTC to CRU, without the signed orders, even though the physician had already entered the orders in the computer. RN states he was concerned when the signed evaluation was not faxed promptly, because the patient was suicidal, upset with being in the triage area and asking to be allowed to go to the residential unit.
The above actions constitute grounds for disciplinary action in accordance with Section 301.452(b)(13) Texas Occupations Code, and is a violation of 22 TEX ADMIN. CODE §217.11(1)(A),(1)(D)&(3).
As a result, the Texas Board of Nursing decided to place his RN license under disciplinary action. It’s too bad that he failed to hire a nurse attorney for assistance, knowing that he had every reason to defend himself in the first place. His defense would have gotten better if he 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 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.