Type: Law Bulletins
Date: 03/25/2016

Ohio Supreme Court Clarifies What Constitutes a "Medical Record" in Recent Ruling

In Griffith vs. Aultman Hospital, the plaintiff (the executor of a deceased Aultman patient’s estate) sued Aultman Hospital alleging that the hospital did not turn over a complete set of medical records requested by the plaintiff. In its opinion, issued on March 23, 2016, the Ohio Supreme Court ruled that the physical location of data, such as the medical records department of a hospital, is not relevant to the determination of whether such data qualifies as a “medical record” under Ohio law. Rather, the focus is on whether a healthcare provider decided to keep the data in the process of a patient’s treatment, and whether the data pertains to the patient’s medical history, diagnosis, prognosis, or medical condition.

Ohio Revised Code 3701.74(A)(8) defines a "medical record" as data in any form that pertains to a patient's medical history, diagnosis, prognosis, or medical condition and that is generated and maintained by a health care provider in the process of the patient's health care treatment. At issue in this case was the meaning of the word “maintain” in the medical record definition. Aultman argued that a medical record consists of information the healthcare provider deems appropriate to maintain in a certain location for the care of the patient (i.e. records sent to the hospital’s medical records department). In contrast, the plaintiff argued that the statute did not authorize the hospital to limit the medical record produced at a patient’s request to include only records that were sent to the medical records department.

Here, the lower court ruled that cardiac monitoring strips, which were printed after the patient’s discharge at the direction of Aultman’s risk management department, and not maintained by the medical records department did not constitute “medical records” under Ohio law. The Fifth District Court of Appeals affirmed and held that medical records consisted of records maintained by the hospital’s medical records department and information that a provider decides not to maintain was not part of the medical record. The Supreme Court reversed and remanded the issue to the trial court to apply its interpretation of the “medical record” definition, described in the opening paragraph above.

Ohio healthcare providers will need to consider the effect of this decision on their medical record practices.

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