Withholding symptoms to avoid legal issues

Nurses General Nursing

Published

My aunt was admitted into ICU and administered NIV. She was struggling with it and hating it -seeming to tire her out and in obvious pain. This went on for 3 days without respite.

I was shocked to see the nursing records dont show anything about her medical condition or physiological condition. (they just record medication given -apparently to avoid any legal evidence of wrongdoing being recorded) Pain is only recorded via a check box in a "nurse care plan which is filled in at 9am" -so if that went "missing" there would be no record of pain.

I am trying to understand what is typically recorded for ICU patients put on NIV? I mean what would be monitored and what are the typical symptoms? Some sample records and any refernces to templates would be very helpful

I am not a nurse but a care giver for 15 years. I'm still reeling from what I'm seeing

TIA

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I was shocked to see the nursing records dont show anything about her medical condition or physiological condition. (they just record medication given -apparently to avoid any legal evidence of wrongdoing being recorded)

How, exactly, do you know what was documented? How is it that you've drawn the conclusion that they document to "avoid any legal evidence of wrongdoing"?

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Specializes in Oncology.

NIV in and of itself isn't painful. What happened after her three days on it, may I ask? It's certainly uncomfortable, but that is usually because you're struggling to breath and trying to avoid intubation.

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What led you to the presumption that the nursing staff are attempting to cover up for something nefarious? What is your background as a "care giver" and what is your prior experience with ICU care?

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It sounds like you have concerns about the care your relative is receiving. The most useful way to address these concerns would be to talk to the nurses and doctors who are providing the care.

As a side note verbalizing or implying that documentation is inaccurate and being done only to protect against legal issues is accusatory and very likely to be counter productive.

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Specializes in NICU, ICU, PICU, Academia.
My aunt was admitted into ICU and administered NIV. She was struggling with it and hating it -seeming to tire her out and in obvious pain. This went on for 3 days without respite.

I was shocked to see the nursing records dont show anything about her medical condition or physiological condition. (they just record medication given -apparently to avoid any legal evidence of wrongdoing being recorded) Pain is only recorded via a check box in a "nurse care plan which is filled in at 9am" -so if that went "missing" there would be no record of pain.

I am trying to understand what is typically recorded for ICU patients put on NIV? I mean what would be monitored and what are the typical symptoms? Some sample records and any refernces to templates would be very helpful

I am not a nurse but a care giver for 15 years. I'm still reeling from what I'm seeing

TIA

How are you getting access to her medical records?

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Specializes in Nephrology, Cardiology, ER, ICU.

We are very sorry for these circumstances and wish you the best. However, AN cannot provide legal or medical advice.

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