A man was admitted to the hospital for surgery. After being transferred out of intensive care to a step-down unit, he developed intermittent atrial fibrillation and was placed on continuous cardiac monitoring.
About four days after his surgery, a nurse in the step-down unit assessed the man and found that he was doing well. About 45 minutes later, an x-ray technician found the man in his 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 man was unresponsive and did not have a heartbeat. Medical personnel resuscitated him and moved him to the intensive-care unit. However, he had suffered severe brain damage and after he made no neurological improvement, his family decided to remove him from life support, and he died.
About two months later, the man’s estate requested a copy of the man’s complete medical record from the hospital. The hospital provided some documents in response to this request. Another written request was made about three months later. The hospital produced the documents that existed in the medical records department for the period the man was in the hospital.
The man’s estate filed an action against the hospital to compel production of the man’s complete medical record under R.C. 3701.74, the Ohio statute setting forth the procedure by which a patient or patient’s representative may obtain a copy of a medical record. The complaint alleged that the hospital had failed to produce any monitoring strips or nursing records from the man’s hospital stay.
In response to interrogatories, the director of medical records and transcription at the hospital verified that the hospital produced the man’s entire medical record. Contemporaneously with the answer, the hospital produced hard copies of cardiac monitoring data from one hour of the man’s hospital stay with the explanation that they were “responsive documents from the visit that are not part of the medical record.”
The director of medical records and transcription at the hospital was deposed. She explained that, while monitoring strips for a patient that are received by her department would be made part of the medical record, the man’s monitoring strips were not part of his medical record because the nursing staff had not provided them to the medical records department. She did not know who directed the nurses not to print his monitoring strips. She stated that his monitoring strips were printed from electronic monitoring equipment after he was transferred from the step-down unit to the intensive care unit or after his death at the direction of hospital risk management and the data in this equipment was not part of the medical record. She did not know when risk management ordered the nurse to print the man’s monitoring strips or whether the nurse printed all the data on the monitor relevant to the man. She stated that the cardiac monitor electronically stored a patient’s data for 24 hours after that patient’s discharge. After 24 hours, however, the information was deleted from the monitor unless a physician ordered that the data be saved. She did not know for how long the data would be saved. She believed that all of the man’s monitoring data was saved.
Subsequently, the hospital produced hard copies of cardiac monitoring data from one other hour of the man’s hospital stay.
The hospital filed a motion for summary judgment arguing that a complete copy of the man’s medical record had been produced. In support, the hospital provided the sworn interrogatory answers of the director of medical records and transcription.
The Stark County Court of Common Pleas granted summary judgment to the hospital. The trial court concluded that the hospital had produced the man’s medical record as defined by the statute.
The Fifth District Court of Appeals affirmed. The appellate court agreed with the hospital that the word “maintained” in R.C. 3701.74(A)(8) pertained only to records that a hospital determined needed to be maintained by a health care provider in the process of a patient’s health care. The appellate court held that the medical record consisted of what was maintained by the medical records department and information that the provider decided not to maintain was not part of the medical record. Documents kept by any other department, including risk management, did not meet the definition of a medical record because they were not maintained by the medical records department.
The Supreme Court of Ohio reversed. The court held that the appellate court erred in holding that a medical record consisted only of information maintained by the medical records department under the statute setting forth the procedure by which a patient or patient’s representative may obtain a copy of a medical record.
The appellate court erred in holding that a patient’s medical record consists only of information maintained by the medical records department under the statute setting forth the procedure by which a patient or patient’s representative may obtain a copy of a medical record. The court reasoned that the physical location of patient data was not relevant to the determination of whether that data qualified as a “medical record” under the statute. The term “medical record” in R.C. 3701.74(B) did not include all patient data, but included only that data that a healthcare provider had decided to keep or preserve in the process of treatment. 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 court found that the definition focused on whether a healthcare provider made a decision to keep data that was generated in the process of the patient’s healthcare treatment and pertained to the patient’s medical history, diagnosis, prognosis, or medical condition. The court held that, for purposes of R.C. 3701.74(A)(8), “maintain,” as used in definition of “medical record,” means that the healthcare provider has made a decision to keep or preserve the patient data. The court reasoned that if the data on the cardiac monitor was saved it would fall under the definition of medical record.
The Supreme Court of Ohio reversed the trial court’s grant of summary judgment in favor of the hospital.
See: Griffith v. Aultman Hosp., 2016 WL 1129209 (Ohio, March 23, 2016) (not designated for publication).
See also Medical Law Perspectives, November 2012 Report: Liability for Electronic and Other Medical Record Information Disclosure
See the Medical Law Perspectives July 31, 2015, Blog: Hospital’s Policies, Procedures Not Discoverable in Vicarious Liability Suit
See the Medical Law Perspectives May 6, 2015, Blog: Hospital Incident Reports Under Scrutiny Again; In Camera Review Found Necessary To Determine Discoverability
See the Medical Law Perspectives March 2, 2015, Blog: Discovery of Hospital Incident Reports: Prepare for In Camera Review; Discovery Likely