Identify the appropriate healthcare legal terminology from the following scenario.
Mrs. Jean Harper was admitted to Richmond Medical Center for hip replacement surgery. Pre-operatively she was administered a prophylactic medication to reduce post-operative gastrointestinal complications as part of the surgeons, Dr. Gilchrist, standing orders. Unfortunately, Mrs. Harper had an allergy to the medication which was listed in her medical record, but went unnoticed by staff. Once the error was recognized, Benedryl was given to conteract the original medication but that caused a steep drop in her blood pressure which led to a stroke. Mrs. Harper suffered dysphasia and hemiplegia which continue to this day.
Mrs. Harper sued Dr. Gilchrist and the nursing staff for damages as a result of the injuries she sustained. Her attorney, Monique LeClair, recognized the need to move quickly to preserve the documentation related to the case.
2. Demonstrate why it is a necessary step in this proceeding.
Next, knowing that RMCs medical records were hybrid, Ms. LeClair needed access to the electronic documents which were part of her patients record along with any e-mails that may have been pertinent to the case.
Documents were then exchanged between the various lawyers and members of the hospital staff gave pretrial oral testimony. Upon reviewing documents from the hospital, Ms. LeClairs team found a metadata discrepancy on an e-form used to document the patients vital signs. The attorney had the court issue an order for nurse responsible for the documentation to appear at the trial. Based on the nurses statement at trial that the document had been altered to reflect constant vital sign monitoring with no substantial change, the deciders of facts supported Mrs. Ramsey and awarded 4.3 million dollars in damages.
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