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Accurate documentation has a huge impact on a patient’s improvement in health recovery. Doing accurate and clear documentation is essential in nursing care. It is also in the clinical guidelines of nursing and is one of many responsibilities of nurses. Some nurses tend to disregard the guidelines of appropriate documentation and then later, regret it. So, if the Board summoned you, hire a nurse attorney for help in facing the Board.

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

On or about September 3, 2020, while employed as an RN at a hospital in College Station, Texas, RN falsely documented that a patient, who presented to the emergency department with complaints of chest pain, dizziness, and weakness, had passed his dysphagia screen, though the complete screen had not been performed. RN’s conduct resulted in an inaccurate medical record and exposed the patient to a risk of harm from undetected and unaddressed difficulties in swallowing, including aspiration.

In response, RN states that the patient was alert and oriented, and stated to RN that he was able to swallow liquids well, so this meant he did not prevent a risk of aspiration. RN states that she checked “pass” in the computer based on what the patient told her, and intended to do the water test shortly, but was distracted by a physician who requested that she obtain a wound culture on another patient. RN states that there was never any malicious intent in her documentation; she was trying to make sure it was perfect and done in real time to suit her preceptor. RN adds that she had been on orientation for two months at the time.

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),(1)(C)&(6)(A).

The Texas Board of Nursing gave the RN enough time to defend the complaints filed against her. However, there was a failure on the RN’s part to find the right RN/LVN license attorney to handle her case. The negligence of the RN/LVN license attorney led to the decision of the Texas BON to place the RN’s license under disciplinary action.

Equip yourself with the knowledge and expertise you need for a successful outcome by consulting a knowledgeable and experienced Texas RN/LVN license attorney. Texas Nurse Attorney Yong J. An is one of those dedicated nurse attorneys who helped represent more than 300 nurse cases for the past 16 years. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679 for a confidential consultation regarding any accusations from the Texas BON.