Ohio Supreme Court Clarifies What Is A “Medical Record”

162017_132140396847214_292624_nIn its decision filed on March 23, 2016, the Supreme Court of Ohio (“Ohio Supreme Court”) ruled that the physical location of the data is not relevant to the determination whether that data qualifies as a medical record in Ohio because 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. 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. The Ohio Supreme Court held 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.

The issue of what is a medical record arose in the context of an Ohio medical malpractice case in which the representative/daughter of a hospital patient repeatedly requested the “complete medical record” of her father, who was found by an x-ray technician to be in his hospital bed with his gown ripped off, the cardiac monitor no longer attached to his body, his central line lying on the floor, and his chest tube disconnected. The patient was later removed from life support and died nine hours later.

The hospital produced the medical record that existed in the medical-records department but failed to produce any monitoring strips or nursing records from her father’s hospital stay. The hospital argued that cardiac-monitoring strips, which were printed after discharge at the direction of the risk-management department, did not meet the definition of “medical record” because they were not kept in the medical-records department.

The Ohio Supreme Court remanded the case to the trial court to determine whether the hospital produced the entirety of the patient’s medical record. The hospital representative had testified that the data on the cardiac monitor is deleted 24 hours after discharge unless it is saved at the direction of a physician. The Ohio Supreme Court stated that if the data was saved at the direction of a physician before discharge, the cardiac monitoring information—and other patient data saved by a healthcare provider but not kept in the medical-records department—would fall under the definition of  “medical record.”

The Ohio Supreme Court further held that the plain language of R.C. 3701.74 does not require that a patient seeking a medical record state a reason for doing so: in establishing a patient’s right of access to medical records, the Ohio General Assembly has not imposed upon the patient or the patient’s representative any burden of demonstrating a reason for accessing the medical record. All that is required of a patient or a patient’s representative is 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.” R.C. 3701.74(B).

Source Griffith v. Aultman Hospital, Slip Opinion No. 2016-Ohio-1138.

If you or a loved one may be the innocent victim of medical negligence in Ohio or in another U.S. state, you should promptly seek the legal advice of a medical malpractice attorney in Ohio or in your state who may investigate your medical malpractice claim for you and represent you in a medical malpractice case, if appropriate.

Click here to visit our website or call us toll-free in the United States at 800-295-3959 to be connected with malpractice lawyers in Ohio or in your state who may assist you.

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This entry was posted on Thursday, April 7th, 2016 at 5:16 am. Both comments and pings are currently closed.

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