Verdicts

A family member brought suit for medical malpractice and several times requested a copy of Griffith's complete medical record. In response, the hospital produced the medical record for the period May 2 through 8, 2012, which was held in the medical-records department. On Dec. 12, 2012, Griffith's representative made an in-person request to see the records and was allowed to review what was represented to her that day as the complete medical record. It contained no monitoring strips or nurse notes, however. Therefore, on Dec. 14, 2012, another written request was made for the medical record and, again, the plaintiff was provided with records held in the medical records department pertaining to Griffith's care between May 2 and May 8, 2012, but they did not contain monitoring strips or nursing records. The hospital had possession of the monitoring information, because it had preserved it for its own risk-management analysis. The plaintiff therefore filed this action to compel the production of Griffith's complete medical record, pursuant to R.C. 3701.74 and 2317.48.

There was much back-and-forth in depositions and testimony on the subject of what constituted “medical records” under the relevant statutes, with the trial and intermediate appellate courts siding with the hospital and finding that the nursing and other disputed records were not part of the medical record because they were never provided to the records department. The appellate majority concluded that the word “maintained” in R.C. 3701.74(A)(8) was addressed only to records that a hospital determines must be maintained by the health care provider in the process of providing patient care; conversely, documents kept by any other department, including risk management, “do not meet the definition of a medical record because they were not 'maintained' by the medical records department.”

Ohio's Supreme Court first noted that the appeal required it to determine what constitutes a “medical record” as that term is used in R.C. 3701.74(A)(8). It then went on to state, “We agree with the Fifth District 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. However, the Fifth District erred in holding that the medical record consists only of information maintained by the medical-records department. The 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.”

Two justices dissented, one asserting that because the monitoring strips were maintained by the hospital's risk management department only after the patient had died, they were never “maintained” for the purposes of patient treatment, and thus fell outside of R.C. 3701.74(A)(8)'s definition of “medical records.” The second dissenter felt that, because the parties had already settled the medical malpractice case by the time the Ohio Supreme Court heard the appeal, the issues the case addressed had become moot. However, the majority addressed this argument in its opinion when it noted that the purpose of R.C. 3701.74 is not only to enable discovery alone, but also to allow a patient to access his records for any reason, which might include his need to seek a second opinion or to transfer his care to another provider.

Stated the majority, “In establishing a patient's right of access to medical records, however, 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.”

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