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There are times when mistakes at work could be inevitable, which is why a nurse attorney can assure full assistance over such errors. Incomplete or inaccurate documentation is just one of the common mistakes an RN or an LVN commits. Disciplinary actions could have been thought about by the Texas Board of Nursing if this particular RN from Bryan, Texas hired a nurse attorney over her case.

At the time of the incident, an RN was employed as a Pediatric Nurse Practitioner at a hospital in Bryan, Texas, and had been in that position for three (3) years and one (1) month.

On or about January 30, 2019, while employed as a Pediatric Nurse Practitioner, the RN failed to accurately document in the medical record of a patient regarding the absence of tonsils, when they had been removed prior to this visit as reacted in the surgical history. Additionally, the RN failed to accurately and completely document, or ensure documentation by others, the patient’s respiratory rate, and the reassessment of vital signs such as temperature and heart rate after interventions were performed. The RN’s conduct resulted in an inaccurate and incomplete medical record, and exposed the patient to a risk of harm in that subsequent caregivers would not have accurate and complete information on which to base their care decisions.

In response to the incident, the RN states that she did document the patient’s tonsillectomy, but she then imported a prescripted exam template that automatically included the statement “normal-appearing tonsils,” which was then overlooked. The RN states that she has now modified her exam template to exclude this pre-scripted language. The RN states that she knows the responsibility of the chart documentation falls on her as the provider. The RN states that she completed this patient’s documentation later, after the clinic was closed, and at that time realized that the initial respiratory rate and vital sign reassessment were not documented by the patient care tech. The RN adds that when she arrived at the clinic the next day to obtain the vital signs from the patient care tech’s log, they were not recorded. The RN states she could not remember the exact numbers so could not chart them, but knows the respiratory rate was normal, and her lungs were clear to auscultation bilaterally, with no coughing.

Therefore, based on the findings of the Texas Board of Nursing, the RN received disciplinary action to ensure further safety and accurate documentation as she works in the future which may also serve as her lesson learned. She could have hired a nurse attorney for instances such as this.

So if you’re summoned by the Board for a hearing against your case if you ever did a minor mistake at work, it’s best to consult a nurse attorney first. For further information and you wish to schedule a private consultation, Nurse Attorney Yong J. An, can assist you by dialing his number at (832) 428-5679. Nurse Attorney Yong J. An, is an experienced nurse attorney who handled various nurse cases since 2006.