The destruction of records can be done when requests for the production of documents legally endanger an organization is performed at the discretion of the health information manager due to storage concerns may be performed in the regular course of business following anspecified retention period should never be performed so that the integrity of patient care is consistently maintained 10 point While conducting the preparation of a record in response to a subpoenareceived on 12/10/18, you realize that there is a potential legal issue with the discharge Wummary. Review and analyze the discharge summary. Give your opinion about the discharge summary that follows and what issue(s) it presents. REASON FOR ADMISSION: 74-year-old white femalo admitted with an infected right hip prosthesis. The patient presented to my office with low-grade fever, nnd slight redness, nccompanied by warmth over the previous incision. She directly admitted to the hospital. HOSPTAL OOURSE: The patient was admitted on 9/19/18 and was immediately started on IV antibiotics. She was encouraged to keep the extremity elevated. A wound culture was taken and returned as MRSA. I then changed the antibiotie to Vancomycin. Daily wound care was provided. During the stay, the patient's smoking was addressed, and I indicated that continued smoking will delay healing and strongly unged the patient to quit smoking. On day one, the patient's hypertension was extremely elevated at 165-110. Cardene was administered and the blood pressure responded, eventually maintaining at 13090. Bdema of her lower extremities was reported and consult obtained. Concern was that her chronic hepatitis C was causing the edema, but consultant felt it was secondary to chronic venous stasis. The patient's progress was slow but steady. Compression was added to the treatment and by 09/24/18 her wound had only minimal redness and swelling was down with compression. The patient was discharged home to self care. DISCHARGE INSTRUCTIONS: The patient was discharged on doxycycline 100mg p.o. b.i.d. 10 days along with pain medication of OxyContin. She was instructed how to perform daily wound care with followup in my office in two weeks. DISCHARGE CONDITION: Stable. D. Stgeine Delitiene Dr. Stephen Williams Dictated: 12/3/18 Electronically signed: 12/4/18 Case Study-Legal terminology 1 Mrs. Barbara White was admitted to Richmond Medical Center for hip replacement surgery Pre operatively she was administered a proplyylactic miedication to reduce postoperative gastrointestinal complications as part of surgeon Dr. Gilcherist's, standing order's Unforturately, Mrs. White had an allergy to the medication, which was listed in her medical record but went unnoticed by staff. Once the error was recosnized, Benadryl was given to counteract the original medication but that caused asteep drop in her blood pressure which led to astroke. Mrs. White sulfered dysphasit and hemiplegia, which continue to this dry; Mrs. White sued Dr. Gilchrist and the nursing staff for damages as a result of the injuries she sustained Her attomey, Monique LeClair, recognized the need to mir. Whieblu th nreserve the documentation related to the case. 1 point Demonstrate why that is a necessary step in this proceeding
