Nursing practice has many rewards but also many challenges. You know why you got into nursing and the substantial value, financial and otherwise, that you draw from it. You likely also know nursing's challenges, both the technical expertise it demands and the physical, mental, and emotional energy and devotion it requires. You may even be familiar with the threat of nursing license suspension and revocation due to things like patient abuse or neglect. However, you may not appreciate the peculiar licensing risk that is associated with your alleged failure to keep accurate patient records. Let the Lento Law Firm's premier Professional License Defense Team help if you face state nursing board charges based on your alleged inability or unwillingness to create and maintain accurate patient records. Call 888.535.3686 or complete this contact form now for our skilled and experienced defense representation.
The Function of Accurate Patient Recordkeeping
As a licensed nurse holding a nursing education and degree, you know that medical and nursing care and practice require recordkeeping. Recordkeeping serves several functions. First and foremost, it accurately records the patient's condition, patient reports, physician orders and compliance with those orders, examination results, lab results, consults, care provided, medications administered, and other events, terms, and conditions surrounding the patient's care. That record then becomes the basis for, among other things, the patient's further care, patient evaluation, patient discharge, insurance billing, and the review of care for accreditation, employment, malpractice, insurance, and other institutional and professional purposes. As healthcare providers and their lawyers and insurers like to say, it doesn't happen if it isn't in the records.
A Nurse's Critical Role in Recordkeeping
You also know that as a nurse, you may have primary responsibility for creating and maintaining accurate patient records. Yes, physicians and nursing supervisors also make record entries. So do managers, supervisors, aides, attendants, and others working in the healthcare setting. But the basic recordkeeping may instead be up to you, with physicians and supervisors largely signing off on records that you created and maintained. Other healthcare workers, the patient, and your employer's managers, billing clerks, and other employees may all rely primarily on you for accurate, complete, and up-to-date patient records. Recordkeeping is, in short, likely a huge and important part of what you do in your clinical setting. No surprise, then, that inaccurate, incomplete, or absent medical records can be the basis for disciplinary charges. Let us help you defend those charges so that you can continue to do the good nursing work that you do.
Impediments to Accurate Recordkeeping
We recognize that keeping accurate, complete, and up-to-date medical records may not seem like your first priority. At times, recordkeeping may feel like an afterthought in the midst of more pressing duties. After all, you have patients whose health, well-being, and lives depend on your prompt and attentive care, communication, and other actions. You surely place patient care above recordkeeping, especially when you find your workplace understaffed and your assignments at the margins of what you are able to handle in the time allotted. A National Library of Medicine study notes these impediments that nurses face to accurate and complete recordkeeping while simultaneously urging continual training in the necessity of such recordkeeping.
Another National Library of Medicine article studying the role of nurses in medical recordkeeping acknowledges as much that nurses have a natural and laudable inclination toward patient care over recordkeeping. Yet the same article promptly reminds nurses that recordkeeping is no afterthought. Instead, it is a vital part of a nurse's core duties. Beware of minimizing the important role your recordkeeping plays. We may be able to help you defend your disciplinary charges based on your work's multiple pressing demands and other impediments to recordkeeping. Yet that argument is no sure defense, given the critical role of accurate medical records.
Reporters of Inaccurate Patient Records
The question naturally arises as to who would complain of inaccurate, incomplete, or out-of-date medical records. When a nurse faces disciplinary charges over, say, patient abuse, the patient or patient's family members are natural complainants and reporters of the abuse allegations. However, patients and their family members don't generally have ready access to medical records. So, who complains of inaccurate records? Treating and examining physicians, consulting physicians, laboratory technicians, hospital or facility pharmacists, nursing supervisors, other nurses, and employer representatives like billing clerks all use medical records. In practice, dozens of healthcare professionals may access a patient's medical records in the regular course of their practice. Any one of those healthcare professionals or employer representatives may complain that your medical records are inaccurate, incomplete, or out-of-date.
Causes of Inaccurate Records Complaints
Complaints of inaccurate records may arise when any one or more of the above healthcare professionals find anomalies in the medical records that interfere with their professional performance. For instance, the physician who cannot make a diagnosis and treatment recommendations because the records lack documentation of patient vital signs, medications administered, responses to other treatments, and other conditions and events may complain to nursing supervisors or employer representatives of your failure to perform adequate recordkeeping. Likewise, a nursing supervisor or nurse colleague who reviews signs off on, or makes entries in, your patient's medical records may be unable to do so in good faith and sound practice if your records are inaccurate or incomplete. The same would be true for a consulting physician, pharmacist, or even a billing clerk who cannot complete invoices and insurance reimbursement requests for lack of documentation you were allegedly responsible for completing. If you can, let us know the moment you face suspicions, reports, or complaints about your recordkeeping before those complaints reach disciplinary officials. We may be able to intercede and advocate for you, heading off disciplinary charges.
Triggers for Recordkeeping Disciplinary Charges
The above discussion of who would discover and report a nurse's inaccurate recordkeeping highlights the question of what triggers a recordkeeping disciplinary charge. In ordinary cases, a nurse's failure to keep accurate medical records may simply result in employment review, perhaps some corrective action plan, and employment termination or limitation if the offending nurse is unable or unwilling to comply. The matter may never reach the state nursing board for investigation and pursuit of disciplinary charges.
But if, instead, the nurse's inaccurate or incomplete medical records cause a patient injury, contribute to substandard medical or nursing care, or lead to malpractice allegations, then those events are more likely to take the matter out of the employment setting and into a disciplinary proceeding. The patient or patient representative may make the disciplinary complainant or, more likely, the offending nurse's supervisor, colleagues, or employer may do so both out of a duty to report and to shift responsibility away from the institution or other healthcare professionals. You may, in other words, get scapegoated for injuries or malpractice that others cause, but who blames your inaccurate medical records?
Potential Consequences of Inaccurate Recordkeeping
The variety of people who may report your allegedly inaccurate records, and the variety of triggering events for disciplinary complaints over allegedly inaccurate records, together highlight the potential adverse consequences of inaccurate or incomplete medical records. Keep these potential adverse consequences in mind when considering the seriousness of your recordkeeping charges. The disciplinary officials who evaluate, investigate, and pursue your recordkeeping charges will have these potential consequences in mind. Our attorneys can help you identify, acquire, and present evidence that your alleged recordkeeping inaccuracies neither caused nor threatened to cause serious adverse consequences. Those potential consequences we may need to address from your allegedly inaccurate medical records include:
- physicians unable to identify patient conditions needing urgent examination and medical care;
- physicians unable to rule out other diagnoses, requiring additional unnecessary examination, testing, or treating;
- physicians providing or ordering inappropriate medical care;
- physicians unable to provide or order appropriate medical care;
- nursing supervisors missing conditions to report to physicians or assign additional nursing care;
- other nurses providing duplicative nursing care, including administering medications already administered;
- patients suffering harm from any of the above errors or omissions induced through the allegedly inaccurate medical records;
- healthcare professionals, employers, and facilities facing civil liability for patient harm due to inaccurate medical records;
- facilities facing accreditation or regulatory compliance issues over inadequate recordkeeping; and
- billing delays, errors, and omissions leading to loss of income or insurance fraud allegations.
State Nursing Board Disciplinary Authority
Your state nursing board, the state agency that granted you a nursing license, will have the authority of your state's Nurse Practice Act or other nursing laws to discipline, suspend, and revoke that license. Nurse Practice Acts and nursing laws across the country routinely provide for license discipline on a wide range of grounds, including violations of nursing practice standards that have to do with inaccurate medical recordkeeping.
The Texas Nursing Practice Act is an example. The Texas Nursing Practice Act's Section 301.452 lists the grounds for license discipline. Those grounds include both “unprofessional conduct in the practice of nursing that is likely to deceive, defraud, or injure a patient” and “failure to care adequately for a patient or to conform to the minimum standards of acceptable nursing practice in a manner that, in the board's opinion, exposes a patient or other person unnecessarily to risk of harm.” The Texas Act and the state board's regulations do not specifically address recordkeeping, but recordkeeping would clearly fall within the minimum nursing standards to which these other grounds refer.
For another example, California's Nursing Practice Act treats nurse discipline for inaccurate recordkeeping in the same manner. The California Business and Professions Code Section 2761 states the grounds on which the California Board of Registered Nursing may discipline a nurse's license. Those grounds include “Incompetence or gross negligence in carrying out usual certified or licensed nursing functions.” Once again, inaccurate recordkeeping can constitute incompetence, even though the California statute does not expressly define incompetence. Instead, California Board of Registered Nursing Regulation 1443 defines incompetence to mean “the failure to exercise that degree of learning, skill, care and experience ordinarily possessed and exercised by a competent registered nurse....” Accurate recordkeeping is clearly within a competent nurse's ordinary skill. Your state nursing board will have the authority to discipline you for inaccurate recordkeeping. Get our defense help.
Nurse Recordkeeping Standards
If, despite your nursing education, examination, and licensure, you have any doubt as to the requirement of accurate medical recordkeeping, a brief examination of nursing standards should resolve that doubt. The American Nurses Association, for example, publishes Principles for Nursing Documentation, articulating the critical role that accurate medical records play in a nurse's competent professional performance. We won't likely be able to defend you based on an argument that accurate recordkeeping isn't a part of a nurse's basic competence. Instead, let us help you present other credible defenses. We may, for instance, be able to obtain a nursing consultant's defense testimony that your medical recordkeeping met nursing standards under all the circumstances of your matter.
Defenses to Inaccurate Recordkeeping Charges
When you face state nursing board disciplinary charges over alleged inaccurate recordkeeping, you likely have grave concerns over your ability to defend and defeat those charges. However, keep in mind that disciplinary charges do not mean that state nursing board investigators have already determined your responsibility for inaccurate records. Instead, those officials may expect that you have a credible explanation for, and even a strong defense against, the allegations. You certainly have the right to present a defense. Our skilled and experienced attorneys may be able to help you show one or more of the following grounds on which to defend and defeat your disciplinary charges for inaccurate recordkeeping:
- your medical records were accurate, complete, and up to date in every respect;
- the allegations that your records were inaccurate are based on misunderstanding or misrepresentation of the facts;
- the allegations that your records were inaccurate are false efforts to conceal errors, omissions, or wrongdoing by others;
- the allegations misidentify you as the inaccurate recordkeeper when others were responsible for the inaccuracies;
- you were not responsible for the involved recordkeeping, while other nurses or healthcare professionals had that responsibility;
- your actions were consistent with the reasonable instructions, orders, and directions of physicians or nursing supervisors;
- your actions did not result in any patient harm or risk of patient harm or other loss or injury;
- your supervisor and employer directed you not to perform the recordkeeping involved in the disciplinary case and
- your supervisor and employer directed you to provide patient care and perform other higher-priority activities in lieu of recordkeeping.
Disciplinary Procedures for Recordkeeping Charges
State Nurse Practice Acts and Administrative Procedure Acts generally define the protective procedures to which constitutional due process rights entitle you when defending state nursing board disciplinary charges threatening your license and nursing practice. Those procedures should provide you with both fair notice of the inaccurate recordkeeping allegations, enough for your reasonable defense, and a fair hearing on the charges before an impartial decision maker. Missouri's nursing laws are an example, incorporating into the section on the grounds for nurse discipline the state's administrative procedures for contested cases. Those usual procedures may also provide for an appeal of an adverse hearing decision and even for civil court review in appropriate cases. We can help you invoke these and other protective procedures for your best defense outcome to inaccurate recordkeeping charges.
Defense Attorney's Role in Recordkeeping Charges
The above protective procedures give our highly skilled and experienced attorneys several opportunities to help you defend and defeat inaccurate recordkeeping charges. When you first receive notice of the disciplinary complaint, we can help you evaluate and answer that complaint in a timely manner, raising your defenses and invoking other procedural rights. Our appearance on your behalf shows state nursing board disciplinary officials that you take the charges seriously and plan to mount an effective defense. We may then be able to arrange an informal resolution conference with the investing officials, at which to present your exonerating and mitigating evidence to argue for early voluntary dismissal of the charges without crippling discipline.
If, instead, the disciplinary officials proceed with formal charges, then we can invoke your right to a hearing, at which we can help you present your testimony, the testimony of other witnesses, and your other defense evidence. We can also cross-examine adverse witnesses. If you have already lost your hearing, then we can take available appeals to argue for reversal of the adverse findings on one or more of the statutory or constitutional grounds. If you have already lost your appeal, we may be able to obtain civil court review and relief. Let us help you exhaust all avenues for relief until you gain an outcome that preserves your ability to practice nursing.
Mitigating Disciplinary Sanctions
Even if your medical recordkeeping left patient records inaccurate, incomplete, or out of date, we may be able to help you make a strong case to mitigate any disciplinary sanctions. Disciplinary allegations of inaccurate recordkeeping are relatively low in the hierarchy of reprehensible nursing wrongs, especially when compared to disciplinary allegations of patient abuse, patient neglect, injurious nursing malpractice, or even drug or alcohol abuse, resulting in intoxicated or impaired nursing practice. Your allegedly inaccurate recordkeeping may not have harmed any patient or exposed any patient to risk. Even if some patient harm or lack of care resulted, that harm might not have been serious relative to the patient's diseased or injured condition and the progress of that disease or the impact of that injury. You may also have had reasonable, if arguably inadequate, excuses for not keeping accurate records, particularly in your other more pressing patient care duties.
Our attorneys may be able to gather evidence of the above mitigating and excusing circumstances to present to state board investigators or at your formal disciplinary hearing. Sometimes, the better defense is not so much to attack credible or strong charges but instead to minimize the case for harsh, punitive sanctions. A case in mitigation does not mean playing on the state board's or other decision maker's sympathies, although your good nursing record and other valuable skills and respected commitments outside of the disciplinary charges can carry considerable weight. A strong case in mitigation can, though, instead show that you are not a practice risk and that patients, your employers, and the public need and deserve your skilled, safe, secure, and competent nursing practice. Let us make that case, even if you are sure that you are responsible for the inaccurate records, as the state board alleges.
Nursing License Reinstatement
If you have already lost your nursing license to revocation, we may be able to help you gain your license's reinstatement. Many state legislatures authorize the state nursing board to offer license reinstatement. Missouri, Michigan, and Tennessee are examples of states allowing nurses to apply for license reinstatement. State nursing boards vary in their rules and regulations on license reinstatement, which the boards typically hold to be discretionary with the board in any case. Some boards permit reinstatement only after license suspension or revocation on certain grounds, after a certain interim period elapses, or on certain conditions and limitations. Most boards permitting reinstatement require some form of presentation or even a board hearing to show rehabilitation and justify reinstatement. We can help you determine your reinstatement rights while also helping you prepare and make the necessary presentation.
Premier Attorneys for Nursing License Defense
If you face state nursing board disciplinary charges for allegedly inaccurate medical recordkeeping, retain the Lento Law Firm's premier Professional License Defense Team for your best defense outcome. Our skilled and experienced attorneys have helped hundreds of nurses and other professionals with successful license defenses on a wide range of issues, including recordkeeping issues. Do not retain unqualified local criminal defense counsel or other unskilled attorney representation. Instead, get the administrative licensing representation you need. We are available in any location across the nation. Call 888.535.3686 or complete this contact form now for the best available nursing license defense representation.