The Ohio Supreme Court ruled today in favor of a daughter of a deceased patient who was not originally provided medical records by Aultman Hospital concerning her father’s death because they were allegedly “not part of the medical record” and were not stored in its medical records department. (Griffith v. Aultman Hosp., Slip Opinion No. 2016-Ohio-1138.)
In a 5-2 decision, the Court stated that the state law definition of “medical record” is not limited to the data maintained by the provider’s medical records department, and the physical location of where the data is stored does not determine if the data qualifies as a medical record.
On May 2, 2012, Howard Griffith was admitted to Aultman Hospital in Canton, Ohio for surgery. After being transferred out of the intensive care unit to another unit, he developed a heart condition that required continuous monitoring. Around 4 a.m. on May 6, a nurse checked on Mr. Griffith and found him doing well. About 45 minutes later, an X-ray technician found Mr. Griffith in his bed with his gown ripped off, the cardiac monitor detached, his central line lying on the floor, and his chest tube disconnected. He was unresponsive and without a heartbeat. While medical personnel resuscitated him, Mr. Griffith had suffered severe brain damage. When he made no neurological improvement, Mr. Griffith was removed from life support on May 7, 2012. He died approximately nine hours later on May 8, 2012.
In July 2012, Howard’s daughter, Gene’a Griffith, requested a copy of her father’s complete medical record. The hospital provided some records, but not all. As a result, she was forced to file suit in Stark County Common Pleas Court alleging that the hospital failed to produce the complete record including cardiac-rhythm monitoring strips and nursing records from her father’s stay. The hospital then produced hard copies of the cardiac monitoring data, but argued they had not been produced earlier because they were “not part of the medical record.”
The trial court granted summary judgment for the hospital finding it produced all of the medical records as defined by R. C. 3701.74(A)(8). The Fifth District affirmed the ruling by a 2-1 vote, finding only the information the provider decides to maintain in the medical records department is a medical record, and records kept by other departments, such as risk management, are not. Ms. Griffith appealed the ruling to the Supreme Court.
In the 5-2 decision, the Ohio Supreme Court stated the state law definition of “medical record” is not limited to the data maintained by the provider’s medical records department, and the physical location of where the data is stored does not determine if the data qualifies as a medical record.
The majority opinion authored by Justice Kennedy reversed the Fifth District Court of Appeals decision. The Court held that:
“***[B]ecause the Ohio General Assembly did not limit the definition of “medical record” in R.C. 3701.74(A)(8) to data in the medical-records department, the physical location of the data is not relevant to the determination whether that data qualifies as a medical record. Instead, the focus is whether a healthcare provider made a decision to keep data that was generated in the process of the patient’s healthcare treatment and pertains to the patient’s medical history, diagnosis, prognosis, or medical condition. We hold that for purposes of R.C. 3701.74(A)(8), ‘maintain’ means that the healthcare provider has made a decision to keep or preserve the data.”
Justice Kennedy also noted that the General Assembly has not imposed upon the patient or the patient’s representative any burden of demonstrating a reason for accessing the medical record. Instead, all the statute requires is for a patient or a patient’s representative to “submit to the health care provider a written request signed by the patient…dated not more than one year before the date on which it is submitted.”
The case was remanded to the trial court to apply the Court’s definition of medical record.
If you are being denied a copy of your medical records, feel free to contact Attorney Pamela A. Borgess of Borgess Law, LLC at (567) 455-5955 or toll-free at (844) LAW-9144. You can also contact Borgess Law, LLC by submitting an online inquiry at www.BorgessLaw.com or emailing Attorney Borgess directly at [email protected]. Borgess Law, LLC never charges a fee for an initial consultation.