Hospitals Can't Hide Your Records in Another Department: Griffith v. Aultman Hospital

Published April 19, 2016 · Ohio Supreme Court

Howard Griffith was recovering from lung surgery at Aultman Hospital in Canton. Because his heart had slipped into an irregular rhythm, he was placed on continuous cardiac monitoring. At 4 a.m. a nurse checked on him and found him doing well. Forty-five minutes later an x-ray technician found him with his gown torn off, his cardiac monitor detached from his body, his central line on the floor, his chest tube disconnected, and no heartbeat. He was resuscitated but had suffered severe brain damage, and his family removed life support two days later.

His daughter did what any family would do. She asked the hospital for his complete medical record. The hospital gave her what its medical-records department had on file. What it did not give her, until she sued, were the printouts from the cardiac monitor covering the critical 51 minutes, which a nurse had printed after his death at the direction of the hospital's risk-management department. The hospital's position was that those printouts were not part of the "medical record" because they were not kept in the medical-records department.

On March 23, 2016, the Supreme Court of Ohio rejected that position in Griffith v. Aultman Hosp., 146 Ohio St.3d 196, 2016-Ohio-1138. The decision matters to every injured person in Ohio who needs to know what actually happened to them in a hospital.

The statute: your right to your record

R.C. 3701.74 gives a patient, or a patient's personal representative, the right to examine or copy "part or all of a medical record" by submitting a signed written request. If the provider does not comply, division (C) allows the patient to sue to enforce the right. The statute is the everyday tool for getting your records before any lawsuit is filed, and it is far faster and cheaper than formal discovery.

The dispute in Griffith was over the definition. Division (A)(8) defines "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 treatment. The hospital argued, and the Fifth District Court of Appeals agreed, that "maintained" meant whatever the hospital chose to route to its medical-records department, so anything held elsewhere, including by risk management, was outside the statute.

What the Court held

Justice Kennedy's majority opinion read the statute as written and found no words limiting a medical record to a particular department or location. The Court held that "maintain" simply means the provider "has made a decision to keep or preserve the data." If the hospital decided to keep information generated during a patient's treatment that relates to his condition, that information is part of the medical record no matter which office holds it. The Court pointed out that Arkansas's statute expressly limits records to those held by the medical-records department; Ohio's General Assembly wrote no such limit, and the Court would not add one.

Two further points in the opinion are just as useful.

First, the Court sent the case back to the trial court to determine whether the hospital had in fact produced the entire record under the correct definition, including whether cardiac-monitor data had been saved at a physician's direction before the monitor's automatic 24-hour deletion. The hospital's own records director had testified that she did not know whether the nurse printed all the data or only some of it. That is the kind of question the hospital now has to answer.

Second, the Court held that R.C. 3701.74 does not require a patient to state any reason for requesting records. The court of appeals had suggested the statute exists so patients can get a second opinion or transfer providers, and one dissenting justice argued the request was pointless because the family's malpractice claim had already settled. The majority rejected both ideas: "All that is required" is a signed, dated written request. You do not have to explain yourself, and the provider cannot refuse because it suspects you are considering a claim.

Why this matters beyond malpractice cases

Griffith arose from a hospital death, but the records problem it solves shows up in ordinary injury cases constantly.

• Monitoring and device data. Cardiac strips, fetal monitoring, pulse oximetry logs, infusion-pump records, and ventilator data are generated by machines and often never make it into the paper or electronic chart. After a crash, surgery or hospital stay, that data can show exactly when a patient's condition changed and whether anyone responded.
• Nursing-home and rehabilitation records. Call-light logs, turning-and-repositioning schedules and incident reports frequently live outside the "chart." The nursing-home pressure-sore verdict I wrote about in December turned on exactly this kind of documentation.
• Risk-management and "quality" files. Hospitals have long argued that anything touched by risk management is privileged. Griffith draws a line: data generated during treatment does not become something else because risk management printed it. Ohio's peer-review privilege remains a separate issue, but it does not swallow a patient's own treatment data. I discussed a related fight over hospital records in this post about an infected surgeon.

How we use R.C. 3701.74 in an injury case

In every serious case, one of the first things our office does is send signed R.C. 3701.74 requests to every provider, asking specifically for the complete record "in any form," including monitoring data, imaging, nursing notes, incident reports and audit trails from electronic systems. After Griffith, a provider who produces only the medical-records department's file has not complied. If a provider stalls or edits, the statute's civil-enforcement provision gives us a direct remedy without waiting for a lawsuit on the underlying injury.

Complete records matter for a second reason I have written about before: what you told your doctors, and what they documented, is evidence in your case, which is why honesty with your physicians matters so much. You should know exactly what is in your file before an insurance company does.

What this means for you

If you or a family member was hurt or died in a hospital, nursing home or other facility, you are entitled to the complete record of what happened, wherever the facility stores it, and you do not have to justify the request. Do not accept a partial production as the whole story. Our personal injury and wrongful death practices obtain and review the full record, including the machine data, before deciding whether a claim exists.