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Maintaining accurate and comprehensive medical records is not only a fundamental responsibility but also crucial for providing patients with safe and effective care. Any inaccuracies or omissions in documentation can lead to misunderstandings, errors in subsequent treatments, and even potential harm to patients. When healthcare providers are involved in incidents related to documentation inaccuracies, a nurse attorney’s expertise can be instrumental. A nurse attorney advocates for the legal rights and professional interests of the RN during any investigations or disciplinary proceedings.

At the time of the initial incident, she was employed as an RN at a supported living facility in New Braunfels, Texas, and had been in that position for three (3) months.

On or about February 28, 2021, while employed as an RN at a health care facility in New Braunfels, Texas, RN documented administration of Levothyroxine and Loratadine to a patient. The medications were scheduled for morning administration and had been appropriately administered by the morning shift. RN failed to amend the documentation to reflect the medications were not actually administered and the initial entry was made by mistake. RN’s conduct created an incomplete medical record and was likely to injure the residents in that subsequent care givers would not have complete information to base their decisions for further care.

In response to the above incident, Respondent states that she immediately realized her error and notified her supervisor, who told her that there was no way to correct the MAR documentation. 

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)(C)&(1)(D) and 22 TEX. ADMIN. CODE §217.12 (1)(A),(1)(B),(1)(C)&(4).

The Texas Board of Nursing then subjected the RN’s license to disciplinary action. The accusation would have been defended by an experienced and skilled nurse attorney, had the RN hired one. Hiring a nurse attorney for defense is applicable for any kind of accusation laid against an RN or LVN.

Always remember that anyone can file a complaint against an RN/LVN with the state board for any reason. When this happens, all complaints need to be taken seriously no matter how trivial or unfounded they may appear. A nurse attorney is someone who can help you defend your license when the state board summons you. Equip yourself with the knowledge and expertise you need for a successful outcome by consulting a knowledgeable and experienced Texas RN license attorney. Texas Nurse Attorney Yong J. An is an experienced nurse attorney for various licensing cases for the past 17 years and represented over 500 nurses before the Texas BON. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679.