What are the Texas Board of Nursing's Rules Regarding Nursing Documentation and Recordkeeping?

As a licensed nurse in Texas, you must follow all the rules and laws that apply to your profession. The Texas Board of Nursing (BON) is the state agency that licenses nurses. BON also takes complaints about nurses, investigates those complaints, and pursues disciplinary action where warranted.

Nurses are subject to various laws and rules relating to recordkeeping and patient documentation. Failure to follow these laws and rules can lead to negative repercussions for your license and your career. Therefore, if you find yourself in this situation, you should take steps to protect your license by enlisting the help of an experienced nursing license defense lawyer.

Standards of Nursing Practice

22 Tex. Admin. Code §217.11 establishes minimum standards of practice for nurses. Violating these standards can result in disciplinary action against a nurse’s license, even if the violation resulted in no injury to a patient. For instance, nurses must accurately and completely report and document the following:

  • the client’s status, including signs and symptoms;
  • nursing care rendered;
  • physician, dentist, or podiatrist orders;
  • administration of medications and treatments;
  • client response(s); and
  • Contact with other healthcare team members concerning significant events regarding the client’s status.

Unprofessional Conduct

22 Tex. Admin. Code §217.12 outlines unprofessional conduct rules that apply to nurses. These rules protect clients and the public from incompetence, unethical acts, and illegal conduct by licensed nurses. Some unprofessional conduct directly relates to nursing documentation and recordkeeping. For example, improperly managing client records is an unsafe practice that violates professional conduct rules. Likewise, falsifying reports, client documentation, agency records, or other documents is misconduct that violates the rules. 

Grounds for Disciplinary Action by the BON

One ground for disciplinary action by the BON under Tex. Occ. Code §301.452(b)(10) is “unprofessional conduct in the practice of nursing that is likely to deceive, defraud, or injure a patient or the public.” Deceitful conduct in the practice of nursing can relate to the creation and maintenance of patient records. 

The BON Disciplinary Matrix sets forth the sanctions for different types of violations by nurses. Under this Matrix, a First Tier Offense related to this section of the Code involves an “isolated failure to comply with Board rules regarding unprofessional conduct resulting in unsafe practice with no adverse patient effects.” It also may involve an “isolated violation involving minor unethical conduct where no patient safety is at risk . . .”. A Level I Sanction for a First Tier Offense that involves behavior that is deemed unintentional may involve remedial education and a fine of $250 or more for each additional violation. However, a Level II Sanction can involve a Warning with Stipulations that may include the following:

  • remedial education;
  • supervised practice;
  • performance of public service;
  • limitations to specific nursing activities;
  • periodic BON review; and/or 
  • a fine of $500 or more for each additional violation.

Furthermore, if the isolated violations are related to the mishandling or improperly documenting controlled substances (absent any evidence of impairment), the Stipulations may include random drug screens.

A Second Tier Offense involves “failure to comply with a substantive Board rule regarding unprofessional conduct resulting in serious risk to the patient or public safety” or “repeated acts of unethical behavior or unethical behavior which places patient or public at risk of harm.” A Level I Sanction provides a Warning or Reprimand with Stipulations similar to a Level II Sanction for a First Tier Offense. However, a Level II Sanction may result in suspension or revocation of one’s nursing license, with no possibility of reinstatement until the payment of fines, completion of remedial education, and presentation of evidence of other rehabilitative efforts to the BON. In addition, this offense level is likely to result in a probated suspension for a minimum of two to three years with BON monitoring and supervised practice, restitution (if applicable), completion of treatment, and one year of sobriety (if related to the mishandling of controlled substances). 

Finally, a Third Tier Offense involves “failure to comply with a substantive Board rule regarding unprofessional conduct resulting in serious patient harm” or “repeated acts of unethical behavior or unethical behavior which results in harm to the patient or public.”  Both Level I and Level II Sanctions can result in the revocation of one’s nursing license. In addition, in the case of a Level II Sanction, the BON may temporarily suspend a nursing license if the violation is a continuing and imminent threat to public health and safety. 

BON Disciplinary Sanction Policy on Behavior Involving Lying and Falsification

BON has issued a Disciplinary Sanction Policy on Behavior Involving Lying and Falsification. While this policy can involve deceptive conduct relating to employment and licensure, it also can involve falsifying documents concerning patient care. This policy outlines the BON’s process for reviewing deceptive and dishonest behavior by nurses. 

Nurses have a general duty to provide safe and effective nursing care and demonstrate reliable professional character. By the nature of their jobs, nurses frequently must report patient conditions, treatment, and subjective and objective information. They also must provide patients with information and report any errors in their practice or conduct. These duties, which nurses should complete honestly and accurately, involve performing and documenting nursing assessments, reporting changes in conditions, promptly acknowledging and reporting errors, and accurately charting each patient. 

As a result, the BON takes the position that “falsification of documents regarding patient care, incomplete or inaccurate documentation of patient care, failure to provide the care documented, or other acts of deception or omission raise serious concerns about an individual’s ability to provide safe nursing care and prevents subsequent caregivers from having a complete and accurate picture of the patient’s care and condition.” Therefore, when a nurse exhibits this behavior, the BON is mindful that similar misconduct can occur in the future, thus jeopardizing effective patient care. 

Regarding disciplinary action, the BON evaluates each case on its own merit. Not all cases involving deceptive conduct require the same level of intervention or even necessitate disciplinary action. Some of the relevant factors that the BON will consider in evaluating each situation include the following:

  • the nature and seriousness of the conduct,
  • the actual harm resulting from the conduct,
  • the individual’s history,
  • premeditation,
  • lack of remorse, 
  • restitution, and/or 
  • the risk the individual’s practice poses to patients and the public.

Find Out More About How to Best Handle Your Disciplinary Proceedings 

We want to help put you in the best position to protect your nursing license. As a result, you need immediate legal representation to defend your license from these potentially severe consequences. At Bertolino LLP, we offer experienced nursing license defense services for those facing disciplinary action. Contact us today by calling (512) 515-9518 or looking us up online. We can analyze the circumstances that led to the complaint against you and determine the right legal strategy for you.

Call or text (512) 476-5757 or complete a Case Evaluation form