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Whenever someone filed a complaint against you, your license could be put in danger if not defended by a San Antonio nurse lawyer. This is exactly what happened to an RN in San Antonio when she was accused of medical documentation error

At the time of the initial incident, the RN was employed as a Registered Nurse in San Antonio and had been in that position for eight months.

On or about August 11, 2018, the RN falsified a physician order for a Hemodialysis patient, in that she wrote a limit for fluid removal during hemodialysis treatments to not exceed 3.5 Liters; furthermore, she entered the aforementioned false order under the name of a physician who was not involved in the patient’s care.

The RN’s conduct created a false medical record and exposed the patient to risk of harm from hypervolemia; including edema, shortness of breath, and elevated blood pressure.

On or about August 16, 2018, through September 15, 2018, the RN violated the boundaries of the nurse/client relationship by providing direct patient care to Hemodialysis a patient, with whom she had a personal relationship, after being instructed by nursing leadership she would no longer be assigned to care for the patient, a directive she disregarded.

Additionally, the RN assisted the patient in leaving the hospital against medical advice (AMA) after the patient had been admitted for pneumonia. Her conduct exposed the patient to a risk of harm in that it could have resulted in confusion between the needs of the nurse and those of the patient.

On or about August 25, 2018, the RN asked a patient care technician assigned to Hemodialysis a patient to change a treatment note since she believed said note made the patient appear to be non-compliant with the dialysis treatment; when the patient care technician refused to amend the note, she improperly deleted it.

The RN’s comment created a false medical record and was likely to injure the patient in that subsequent caregivers would not have accurate and complete information on which to base their care decisions.

On or about August 28, 2018, the RN failed to document a plan of care for a patient. Her conduct created an incomplete medical record that was likely to injure the patient in that subsequent caregivers would not have accurate and complete information on which to base their care decisions.

During the hearing, the RN states she did write a fluid removal limit in the special instructions section of the treatment sheet. The RN states the patient experienced a hypovolemic emergency, requiring intervention. The RN states she only documented detailed nursing notes on care provided to the patient.

The RN further states the clinic is guilty of falsifying and manipulating medical records. The RN states the care plan was not completed on time and also states the physician was aware. She further states the physician-assisted with completing the care plan.

Do not fret if you find yourself in a similar situation same as that of the RN mentioned above. All you need to do is to find the right San Antonio nurse lawyer who can help you in the case. Equip yourself with the knowledge and expertise you need for a successful outcome by consulting a knowledgeable and experienced San Antonio nurse lawyer. Contact the Law Office of Yong J. An and text or call attorney Yong 24/7 at (832) 428-4579