You are an administrator for Big City Hospital Inc., a large medical center. Your medical center has just received a Summons indicating that a Complaint has been filed in the state district court in your city claiming that Dr. Quick, Nurse Sleep, and your medical center were negligent during a recent surgery. The claim is that the doctor left before the surgical count, the nurse didn't notice a missing sponge during the count, and the patient now has an x-ray showing that there is a sponge in the abdomen. The medical records do not reflect that a sponge count was even completed. Your state of Maryland has an arbitration process that has been completed and the lawsuit has started. As part of the lawsuit, you receive a litigation hold letter requesting that all documents related to the lawsuit be preserved including electronically stored information (ESI). 

Why is it important to preserve documents for litigation?  How would you do this? 

Describe three actions you would take to preserve documents (prevent destruction) for this lawsuit. 

What key documents would need to preserve because they relate to what happened? 

When a case goes to court, good medical record documentation can make the difference in winning or losing a lawsuit.  How can medical record documentation limit or increase legal liability? 

What should a strong medical record include? 

As a result of this lawsuit, what three actions would you take to improve medical record surgical care documentation including adequate documentation of the sponge count?