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Medical Records should be documented with complete and accurate information of patients along with correct administered medications. Tampering or altering medical records is illegal and is a crime punishable with fines and jail time. By doing such, can mislead and can cause harm to patients. However, if you are dealing with such accusations or complaints, it is best to seek help from a nurse attorney.

At the time of the incident, she was employed as an RN at a medical facility in New Braunfels, Texas, and had been in that position for five (5) years and two (2) months.

On or about August 10, 2020, while employed as an RN at a medical facility in New Braunfels, Texas, RN failed to accurately and completely document her assessment and interventions performed on the patient during an appointment for a colposcopy in that RN documented the patient’s status as “tolerated well” despite documentation that the patient was scared and nervous and RN’s recollection that the patient struggled with anxiety and pain; failed to document a pain assessment; and failed to document interventions performed when the patient experienced a syncopal episode after the colposcopy procedure. RN’s conduct resulted in an inaccurate and incomplete record and was likely to injure the patient in that subsequent caregivers would not have accurate and complete information on which to base their decisions for further care.

In response, RN states that the biopsies were obtained with difficulty as the patient struggled with anxiety and pain during the procedure. RN states that the patient had a syncopal episode following the procedure, for which RN performed interventions, and there was a complete recovery in less than two minutes. RN states that syncopal episodes of this nature are not uncommon.

The above action constitutes 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).

Unfortunately, the Texas Board of Nursing found her guilty of her deeds. Her RN license was subjected to disciplinary action. She did not hire a skilled Texas BON attorney to fully defend her case which led to this decision by the Texas Board of Nursing.

Do you have questions about the Texas Board of Nursing disciplinary process? Contact The Law Office of Texas Nurse Attorney Yong J. An for a confidential consultation by calling or texting 24/7 at (832) 428-5679. Texas Nurse Attorney Yong J. An is an experienced nurse attorney who represented more than 300 nurse cases for RNs and LVNs for the past 16 years.