Ohio Supreme Court Rules that Medical Records Extend Beyond Those Kept in the Medical Records Department

Posted on April 4th, 2016 by sutteroconnell

On March 23, 2016, the Ohio Supreme Court determined what constitutes a “medical record” under R.C. 3701.74(A)(8). The Court reversed the Fifth District Court of Appeals and held that the physical location of data is not relevant when determining what qualifies as a medical record because R.C. 3701.74(A)(8) does not limit the definition of “medical record.” Rather, the focus should be on whether the medical provider kept the data generated in the process of a patient’s healthcare treatment and whether the data pertains to a patient’s medical history, diagnosis, prognosis, or medical condition.

In Griffith v. Aultman Hospital., Slip Opinion No. 2016-Ohio-1138, the plaintiff was placed on continuous cardiac monitoring after developing atrial fibrillation. The plaintiff was later found with his gown ripped off, the cardiac monitor detached, his central line removed and his chest tube disconnected. After being found unresponsive, he was resuscitated and removed to ICU; however, the plaintiff suffered severe brain damage and died after being removed from life support. A few months later the plaintiff’s family requested a full copy of his medical records and the hospital produced the records from the medical records department. The plaintiff’s family again requested the entire medical records and the hospital again produced the records maintained in the medical records department.

This matter was then filed under R.C. 3701.74 and 2317.48 to compel the plaintiff’s complete medical record, including the cardiac monitoring strips. In response to discovery, the hospital produced the cardiac monitoring strips “as responsive documents from the visit that are not part of the medical record.” The plaintiff’s family learned through the deposition of the hospital’s medical records director that the cardiac monitoring printouts were not part of the medical records because the nursing staff had not provided them to the medical records department. On her errata sheet, the director stated that the cardiac printouts were printed after the plaintiff died “at the direction of hospital Risk Management.”

The trial court granted the hospital’s motion for summary judgment because the hospital produced the plaintiff’s medical records under R.C. 3701.74(A)(8). The Fifth District affirmed the decision and found that the word “maintained” in R.C. 3701.74(A)(8) only included records that a “hospital determines need to be maintained by a health care provider in the process of a patient’s health care” and “not everything having to do with the patient.” Ultimately, a patient’s medical records consisted of those records maintained by the medical records department.

The Supreme Court agreed that the term “medical record” in R.C. 3701.74(A)(8) “does not include all patient data but includes only that data that a healthcare provider has decided to keep or preserve in the process of medical treatment” but went on to hold that The Fifth District was incorrect that medical records are only those maintained by the medical records department.  The Court analyzed the legislative history of R.C. 3701.74(A)(8) and the definition of “medical record” as “data in any form that pertain to a patient’s medical history, diagnosis, prognosis, or medical condition and that is generated and maintained by a healthcare provider in the process of the patient’s health care treatment.” The Court applied a common meaning to the word “maintain” and found it to mean that the healthcare provider made a decision to keep or preserve the data.  Furthermore, the statute does not include any language that the medical records must be kept in a specific location.

Justices O’Donnell and Lanzinger wrote dissenting opinions. Justice O’Donnell’s argued that “records generated and maintained by a healthcare facility’s risk management department for risk-management purposes following the death of a patient are not records ‘used in the process of a patient’s health care treatment,’ and therefore, they are not ‘medical records’ as defined” in the statute. Here, the plaintiff’s cardiac monitoring data was printed after he died and was no longer receiving medical care so the records could not have been maintained to assist in any patient treatment.

Justice Lanzinger’s dissent set forth two arguments. First, no real controversy exists because the claim for production of documents and medical malpractice rely on the medical care provided to the plaintiff.  Second, R.C. 3701.74(A)(8) permits healthcare providers to exercise discretion in generating and retaining a specific set of records for a patient’s treatment.

This ruling is important to healthcare providers as it could change the record keeping processes currently being implemented at healthcare facilities. Additionally, given the facts of this case, healthcare facilities will need to be cautious about information requested or gathered by the risk management department as it may later be discoverable as medical records. In the future, healthcare facilities will most likely see discovery requests more pointed to this case by requesting information that was not printed and the details surrounding any decision. This ruling may create additional causes of action in medical malpractice cases if plaintiffs’ counsel are skeptical whether they received the entire medical chart.

For a full copy of the opinion, please click here.