Ohio Supreme Court Refines “Medical Records” Definition in Griffith v. Aultman Hospital

In Griffith v. Aultman Hospital, the Ohio Supreme Court recently reversed the Fifth District Court of Appeals (located in Canton) on the question of what constitutes “medical records” in Ohio, such that they must be produced to a patient upon request. The court of appeals had held that the medical records that must be produced upon request are those that are maintained by the hospital’s medical records department and for which medical providers made a decision to keep or preserve to further the treatment process. The Supreme Court’s ruling preserved part of this standard, but did so in a way that expands the concept of what is a medical record to include all “records” regardless of where in the hospital they are kept, or which department of the hospital keeps the records. This new standard will almost certainly prove cumbersome and may ultimately be unworkable. For example, records kept by risk management departments, multi-disciplinary committees, and by IT departments (including extremely large volumes of electronic records that are never reduced to print) may now be discoverable. Many sophisticated testing procedures can produce thousands and thousands of theoretical “records,” a small fraction of which are relied upon and preserved by medical records departments. Justices Terrence O’Donnell and Judith Lanzinger dissented and would have defined medical records consistent with the court of appeals. Justice Lanzinger succinctly recognized the practical implications raised by the AMCNO in its amicus brief as follows:

The judgment of treating healthcare providers must be relied upon to determine what is (or is not) part of a patient’s medical record, those providers being best able to determine what information is relevant to a patient’s treatment. Hospitals and other providers have teams of employees dedicated to collecting and maintaining this information, and, as the amici curiae have noted, many hospitals have multidisciplinary committees that determine what information should be included in a medical record. The information in the medical record presents the relevant and necessary information that is always subject to being supplemented in the clinical judgment of the treating providers.

The Supreme Court remanded the Aultman decision to the trial court to reconsider what must be produced under the facts of that case. The majority decision did recognize “that the term “medical record” in R.C. 3701.74(B) 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 treatment.” But the opinion is less clear where it states that “[t]he statute defines ‘medical record’ to mean any patient data ‘generated and maintained by a health care provider,’ without any limitation as to the physical location or department where it is kept.”  

An initiative with the Ohio Legislature to clarify the meaning of R.C. 3701.74 could prove helpful on this issue. Nobody is looking to prevent patients from having full access to their medical records. But at the same time, hospitals and other medical providers should not be burdened with large-scale additional documental retrieval responsibilities that will be extremely time consuming but add little substance to questions of whether medical negligence occurred.

For more information on the court’s ruling, click here.

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