The Ohio Supreme Court ruled the state law definition of “medical record” is not limited to the data maintained in the provider’s medical records department.

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Ohio Healthcare Providers – Definition of “Medical Record” and
Where It Is Stored May Have Changed
PRACTICE AREA / INDUSTRY: HEALTHCARE
Robert B. Graziano Michael R. Traven
robert.graziano@fisherbroyles.com michael.traven@fisherbroyles.com
239-877-3077 614.721.5573
March 25, 2016
Hospitals and healthcare provider facilities are facing a new conundrum regarding the retention and location
of data generated during the course of treating a patient. In Griffith v. Aultman Hosp., Slip Opinion No. 2016-
Ohio-1138, issued this week by the Ohio Supreme Court (click here to view the opinion), the Court ruled the
state law definition of “medical record” is not limited to the data maintained in 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 5-2 majority opinion reversed a Fifth District Court of Appeals decision
that limited the information to what was maintained by Aultman Hospital’s medical records department.
At the center of this case is whether data captured and stored on a cardiac monitor, including the print
out of cardiac-rhythm monitoring strips, is part of the patient’s medical record if that data was not provided
by the nursing staff to be included in the patient’s medical record, which in turn, was “maintained” by the
medical records department. Following her father’s death, Gean’a Griffith requested medical records
from Autlman Hospital. The hospital produced the records maintained in its medical records department.
Ms. Griffith made a follow-up request for the complete medical record. The hospital again produced the
records maintained in the medical records department. Then, Ms. Griffith filed a lawsuit in Stark County
Common Pleas Court alleging the hospital was not producing the complete record, specifically
referencing the failure to produce the cardiac-rhythm monitoring strips and nursing records. The hospital
then produced hard copies of the cardiac monitoring data as part of the litigation request but characterized
them as “not part of the medical record.”

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Relevant Case Background
At Autlman Hospital, monitoring strips are typically received by the department and are made part of the
patient’s medical record. Additionally, the cardiac monitor data is electronically stored for 24 hours after a
patient is discharged and then deleted unless a physician orders it to be saved. Mr. Griffith’s printouts were
not part of his record, however, because the nursing staff did not provide them to the medical records
department. But, further discovery revealed that the strips were printed out by the hospital’s risk management
department shortly after Mr. Griffith’s death. According to the hospital in its motion for summary judgment,
because the strips were printed out by the risk department and never provided to the medical records
department, the strips were not part of the patient’s medical record.
Summary judgment for the hospital was granted, finding it produced all of the medical records as defined by
R.C. 3701.74(A)(8). On appeal, 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. The appellate court held that, under R.C.
3701.74(A)(8), documents maintained 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.” The
Ohio Supreme Court disagreed and reversed.
Supreme Court Ruling and Analysis
In the majority opinion written by Justice Sharon L. Kennedy, the Court considered the definition of “medical
record” as it is used in R.C. 3701.74 (A)(8). The majority concluded that, because the Ohio General Assembly
did not limit the definition of “medicalrecord” in R.C. 3701.74 (A)(8) to data in the medical records department,
the physical location of the data is not relevant as to the determination whether the data qualifies as a medical
record. The focus is whether a healthcare provider made a decision to keep data that was generated in the
process of the patient’s healthcare treatment and pertains to the patient’s medical history, diagnosis,
prognosis, or medical condition. Therefore the Court held that for purposes of R.C. 3701.74(A)(8), “maintain”
means that the healthcare provider has made a decision to keep or preserve the data. The Court reversed
the judgment of the Fifth District Court of Appeals and remanded the matter to trial court to determine whether
the hospital met its burden on a motion for summary judgment to show it had produced the entire “medical
record” in accordance with the Supreme Court’s decision.
In a dissenting opinion, Justice Terrence O’Donnell noted that, because the cardiac monitoring records were
generated and maintained by the hospital’s risk management department, they were not records used in the
patient’s healthcare treatment and are not medical records as defined by law. “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

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medical provider in the process of the patient’s health care treatment,” he wrote. Because the monitoring
strips were generated following Mr. Griffith’s discharge, Justice O’Donnell believes the records did not meet
the plain language definition of “medical record” under the statute.
Justice Judith Ann Lanzinger also dissented stating that she would have dismissed without a decision on the
medical records issue because the wrongful death claim had been settled between the parties. She wrote
that the judgment of healthcare providers must be relied on, and they are best able to determine what
information is relevant to a patient’s treatment. She wrote that the language of R.C. 3701.74(A)(8) “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.”
Impact to Healthcare Providers
Healthcare providers should pay special attention to this ruling, as it could alter the manner in which medical
recordkeeping processes and procedures are implemented. Most importantly, this decision should cause
healthcare providers to pay special attention to the information gathered by risk management departments.
Moreover, this decision may create new avenues of litigation in medical malpractice cases for plaintiffs who
may speculate regarding the scope of available medical records, and who want to improperly seek the
contents of a risk management file.
For further information on the subject matter of this alert, please contact the following FisherBroyles attorneys:
Columbus
RobertB. Graziano
(239) 877-3077
robert.graziano@fisherbroyles.com
Columbus
Michael R. Traven
(614) 721-5573
michael.traven@fisherbroyles.com