The Importance of Accurate Documentation Under Missouri Law

Accurate documentation isn’t just a best practice—it’s a legal obligation under RSMo § 335.066(6), which defines falsification or omission of records as unprofessional conduct. Hospitals in St. Louis, Kansas City, and Columbia rely on meticulous charting to ensure patient safety and continuity of care. When records are missing, late, or inconsistent, the MSBN assumes negligence or dishonesty.

How Documentation Problems Arise

Most documentation issues stem from understaffing and time pressure. A nurse covering multiple patients may forget an entry or complete it later, only to face allegations that the information was falsified. Electronic health-record audits can show delayed entries as “alterations,” even if the change simply corrected a clerical error.

Employers must report serious charting discrepancies to the Board under § 335.066(10). Once notified, the Board opens an investigation and reviews the nurse’s entire employment history. Investigators request medication logs, witness statements, and system access reports.

Building a Documentation Defense

When defending documentation allegations, I emphasize intent and patient outcome. Was the entry delayed due to workload or an attempt to conceal wrongdoing? Did the error cause actual patient harm? Demonstrating a consistent record of competent practice, supportive testimony from colleagues, and remediation efforts (such as documentation training) can convince the Board that discipline is unnecessary.

We also examine employer responsibility. Many facilities in Missouri lack adequate documentation policies or training, and nurses should not bear full blame for systemic failures.

Call Us Today!
If you’re accused of charting errors or falsifying patient records, contact Sanger Law Office, LLC at (816) 520-8040. We represent nurses in Kansas City, Jefferson City, and across Missouri, protecting your license from unfair documentation-based complaints.