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MRR Article: Ohio Supreme Court Decides ‘What Constitutes a Medical Record in Personal Injury Suits’ in Griffith v. Aultman Hospital

Griffith v. Aultman Hospital, 2016-Ohio-1138

On March 23, 2016, the Ohio Supreme Court published its Slip Opinion in Griffith v. Aultman Hospital, a Decision which will have significance relative to the production of medical records in personal injury suits. Specifically, the case rules on what constitutes a medical record under Ohio law, which impacts how hospitals and other health care providers will respond to requests for medical records in the future.

The Plaintiff was Gena’a Griffith, whose father, Howard, was admitted to defendant Aultman Hospital on May 2, 2012 for surgery. Following surgery, Mr. Griffith was transferred from intensive care to a step-down unit to continue his recovery. In the step-down unit, Mr. Howard somehow became disconnected from his cardiac monitor, central line, and chest tube. He suffered severe brain damage and ultimately passed away on May 8, 2012.

On July 24, 2012, Plaintiff requested a copy of Mr. Griffith’s complete medical record. The hospital provided only some documents in response. Plaintiff filed two other requests for medical records, but alleged that the records she received were not complete and she subsequently filed suit. Specifically, Plaintiff claimed that the hospital had failed to produce any monitoring strips or nurse records from Mr. Griffith’s hospital stay. The hospital contended the rhythm strips did not meet the legal definition of medical records because the records were housed in a different location and the hospital was therefore not required to print them. Further, the hospital argued that the data produced from electronic monitoring equipment is not part of a patient’s medical record.

Before the Supreme Court of Ohio was the issue of what constitutes a “medical record” as the term is used in Ohio Revised Code Section 3701.74(A)(8). The Court reasoned that because the legislature did not specifically define “maintain” in R.C. 3701.74, the normal, common meaning would apply. The Court defined maintain as “to continue in possession of.”  The Court then held that contrary to the hospital’s assertion, the definition of “maintain does not depend on a managerial decision to keep or preserve the data in a discrete location or file.” The Court found that the physical location of patient data is not relevant in determining whether the data qualifies as a medical record. Instead the Court opined that the inquiry should focus on whether a healthcare provider made a decision to keep data that was generated in the process of the patient’s treatment and pertains to the patient’s medical history, diagnosis, prognosis, or medical condition.

With regard to whether the hospital met its burden in producing the entirety of Mr. Griffith’s medical records, the Court reasoned that if the rhythm strips were saved at the discretion of a physician before Mr. Griffith’s passing, the information would fall under the definition of “medical record” and would need to be produced. The Court ultimately remanded to the trial court on the factual issue of whether Mr. Griffith’s physicians recommended that the rhythm strips be saved in the course of treating Mr. Griffith.

Finally, the Court held that “the plain language of R.C. 3701.74 does not require a patient seeking a medical record [to] state a reason for doing so.” This holding overrules language from the lower court which limited the scope of R.C. 3701.74 to simply enabling a patient to obtain his file to find a second opinion or transfer to another medical provider. Rather, all that is required of a patient or patient’s representative is to submit a written request.

Overall, the Court’s conclusions in Griffith will place a greater burden on hospitals to maintain all medical records and be able to produce all such records upon request of a patient or patient’s representative. The practical effect of this decision from a defense attorney’s perspective is that it will become somewhat easier to obtain a full medical record in a personal injury case. Griffith dictates that hospitals provide all “data that was generated in the process of the patient’s treatment and pertains to the patient’s medical history, diagnosis, prognosis, or medical condition.” Defense attorneys, and their clients, will be able to not only obtain a full medical record, but will be able to do so without having to state a reason for their request.