Patient Medical Records Data Not Confined to What Is Kept by Medical Records Department
All data that healthcare providers make a decision to keep that was generated in the process of a patient’s treatment and pertains to the patient’s medical history, diagnosis, prognosis, or medical condition is a medical record, the Ohio Supreme Court ruled today.
In a 5-2 decision, the Supreme Court stated the state law definition of “medical record” is not limited to the data maintained by the provider’s medical records department, and the physical location of where the data is stored does not determine if the data qualifies as a medical record.
The majority opinion, authored by Justice Sharon L. Kennedy, reverses a Fifth District Court of Appeals decision that limited the information to what was maintained by Canton’s Aultman Hospital’s medical records department.
Daughter Seeks Information on Father’s Death
On May 2, 2012, Howard Griffith was admitted to Aultman for surgery, and after being transferred out of the intensive care unit to another unit, he developed a heart condition that required continuous monitoring. Around 4 a.m. on May 6, a nurse checked on Howard and found him doing well. About 45 minutes later, an X-ray technician found Howard in his bed with his gown ripped off, the cardiac monitor detached, and his chest tube disconnected. He was unresponsive and without a heartbeat.
Howard was moved to intensive care where he was diagnosed with having suffered severe brain damage. With no sign of improvement, his family decided to remove him from life support, and he died about nine hours later.
In July 2012, Howard’s daughter, Gene’a Griffith, requested a copy of her father’s complete medical record. The hospital provided some records, but Griffith asked for more in October, and the hospital produced the records from the medical records department from the time Howard entered the hospital until he died. After Griffith had a representative review in-person what the hospital characterized as the complete medical record, she made another written request in December and was given the same records as produced in October.
She then filed a lawsuit in Stark County Common Pleas Court alleging the hospital was not producing the complete record including cardiac-rhythm monitoring strips and nursing records from her father’s stay. The hospital produced hard copies of the cardiac monitoring data as part of the litigation request but characterized them as “not part of the medical record.”
Jennifer Reagan-Nichols, Aultman’s director of medical records and transcription, testified the hospital produced the cardiac rhythm strips from 4 a.m. until 4:51 a.m., around the time Howard was discovered, in response Griffith’s records request. She explained that while monitoring strips that are received by her department will be made part of the medical record, Howard’s printouts were not part of his record because the nursing staff did not provide them to the medical records department.
The hospital sought summary judgment, arguing the complete copy of the medical record had been produced, and that the rhythm strips do not meet the definition of a medical record.
The trial court ordered a second deposition of Reagan-Nichols to clarify the hospital’s position on the nature of the rhythm strips and whether Griffith was provided all the strips she requested from the morning of her father’s death. The hospital said the data in the monitoring equipment is not part of the medical record and that the strips were printed out after Howard was discharged by the hospital’s risk management department. Reagan-Nichols stated the cardiac monitor data is electronically stored until 24 hours after a patient is discharged and then deleted unless a physician orders it to be saved. After the deposition, the hospital produced a rhythm strip from about 3 a.m. May 3.
The trial court granted summary judgment for the hospital finding it produced all of the medical records as defined by R.C. 3701.74(A)(8). The Fifth District affirmed the ruling by a 2-1 vote, finding only the information the provider decides to maintain in the medical records department is a medical record, and records kept by other departments, such as risk management, are not. Griffith appealed the ruling to the Supreme Court.
Physical Location Does Not Define Record
Justice Kennedy wrote the Court agreed with the Fifth District that not all patient data is a medical record as defined by the law, and is limited to the data a healthcare provider keeps or preserves in the process of treatment. The law defines a medical record as “data in any form that pertains to a patient's medical history, diagnosis, prognosis, or medical condition and that is generated and maintained by a health care provider in the process of the patient's health care treatment.”
She explained that the definition of “maintain” lies at the heart of the dispute, with the hospital claiming the word means it has discretion to bring the data it collects into a discrete set of records it maintains. The hospital also argued a medical record consists of the information the provider deems appropriate to maintain in a discrete location.
Justice Kennedy wrote the Ohio General Assembly did not define “maintain” in the statute, and the word has not “acquired a technical or particular meaning, whether by legislative definition or otherwise.” The Court determined the ordinary, common meaning of “maintain” is to “continue the possession of,” and in this case it means any data a healthcare provider decided to keep or preserve.
She noted the law does not require the medical record be kept in a specific physical location, and the determination of whether the data is a medical record is based on whether a healthcare provider made a decision to keep data that was generated in the process of a patient’s healthcare treatment and pertains to the patient’s medical history, diagnosis, prognosis, or medical condition.
Justice Kennedy also noted that 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. Instead, all the statute requires is for a patient or a patient’s representative 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.”
The case was remanded to the trial court to apply the Court’s definition of medical record.
Justices Paul E. Pfeifer, Judith L. French, and William M. O’Neill joined the opinion.
Chief Justice Maureen O’Connor concurred in judgment only.
Justice O’Donnell Suggests Data Was Risk Management Records
In a dissenting opinion, Justice Terrence O’Donnell noted the cardiac monitoring records were generated and maintained by the hospital’s risk management department for risk management purposes. They are not records used in the process of a patient’s health care treatment and therefore are not medical records as defined by the law, he asserted.
Justice O’Donnell noted that Reagan-Nichols testified the hospital does not maintain all the data generated during a patient’s stay and if the hospital printed out all the data from the equipment monitoring a patient, it would results in “loads of paper” in the chart. She testified that a doctor or nurse has the discretion to make printouts from monitoring strips and send them to the medical records department, but the monitoring equipment is not accessible to the department and the data in the equipment is not maintained by the department.
Justice O’Donnell explained that the medical data that exists or has been generated and maintained by a hospital does not automatically require it be produced as a medical record.
“The legislature could have mandated that health care providers maintain and produce all patient data generated for any purpose, but it did not do so. Rather, it particularly specified that medical records are those generated and maintained by a medical provider in the process of the patient’s health care treatment,” he wrote.
Justice O’Donnell concluded that the hospital monitored Griffith’s heart but did not maintain the data in the process of his treatment. Rather, the risk management department produced monitoring strips after Howard was discharged for its own purposes; at that point, he explained, the hospital was no longer providing any medical care to him, the risk management department could not have generated and maintained that data “in the process of the patient’s health care treatment,” and the hospital therefore had no obligation to provide the data to Griffith.
Justice Lanzinger Maintains Providers Have Discretion
Justice Judith Ann Lanzinger also dissented, noting she would have dismissed the case without deciding the medical records dispute because Griffith’s wrongful-death claim against the hospital was settled and there was no ongoing dispute between the parties. She stated the majority “sidesteps” Aultman’s argument that the hospital has discretion in deciding what data should be made part of the medical record.
She wrote that the judgment of treating healthcare providers must be relied on, and they are best able to determine what information is relevant to a patient’s treatment. Hospitals and providers have multiple employees collecting and maintaining data, she noted, and many hospitals have committees determining what information needs to be included in the medical records.
“While a medical record may include data in any form, R.C. 3701.74(A)(8) specifies that in order for data to be a part of the medical record, that data must be generated and maintained by the healthcare provider in the process of the patient’s health care treatment,” she wrote. “This language implies that it is within a hospital’s discretion, through its employees, to select, preserve, and store records relevant to the health care provider of a particular patient in the manner it sees fit.”
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