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M2A2 – Case Study: Legal Records Hold Policy

When a hospital suspects a patient is planning to sue due to some issue or dissatisfaction they have with the hospital, provider and/or treatment received, the hospital will place the medical record on legal hold to prevent any documentation being added, changed, or deleted. The point is to preserve the documentation as it was at the time of the incident. Unfortunately, some providers may also know about the potential lawsuit and try to delete, add, or change information to assist with proving their innocence during litigation.

Your organization has had notice of a lawsuit recently. The record was placed on legal hold. However, weeks earlier a charge nurse had been told by the family member that they intended to sue. Ideally, it would have been best to put this medical record on hold at the time this charge nurse was made aware of this potential lawsuit. This has caused some documentation problems, whereby the time the notice for the lawsuit was received, some documentation had already been destroyed.

Your facility is now reviewing the policy and procedure for E-discovery and Legal Records Hold. Review and analyze the following policy and procedure and create suggestions for modifications to this policy that could help prevent future issues. You should create a minimum of four suggestions for modifications.

Community Hospital

Legal Hold Policy and Procedure

Purpose: To prevent spoliation of evidence in the event or anticipation of litigation, this policy addresses the process for retention and preservation of health records.

Policy: It is the policy of Community Hospital to preserve all forms of health information (paper or elecgtronic) when litigation is anticipated and to initiate a legal hold process that prevents destruction of said information until the legal hold is lifted to prevent spoliation.

Procedure:

  1. Legal hold is issued
  2. Appropriate data stewards are notified of legal hold
  3. Preservation process initiated
  4. Review and update legal hold notices as appropriate
  5. Assign responsibility for oversight of legal hold notices
  6. Audit and track compliance with legal holds
  7. Release legal hold when no longer needed
  8. Review other legal holds to ensure no overlap
  9. Via written notice, alert data stewards of lifting of the legal hold
  10. Commence normal retention and destruction schedule of health record

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