Issue link: https://viewer.e-digitaledition.com/i/674833
MOST HE ALTHCARE PR ACTITIONERS probably give little thought to what constitutes a medical record or where they keep patient records. When a patient requests his or her records, the sta– copies the patient's chart or prints out electronic records and provides them to the patient. However, a recent case decided by the Ohio Supreme Court demonstrates recent e–orts by patients (and patients' attorneys) to broaden the definition of "medical record" to obtain more ammunition for potential lawsuits. In that case, a hospital patient passed away after su–ering a cardiac event following surgery. The patient was discovered in his bed with the cardiac monitor detached and chest tube disconnected. The patient's daughter attempted to obtain her father's "complete" medical records. She eventually filed a lawsuit alleging that the hospital had failed to turn over monitoring strips and nursing records from her father's stay. The hospital claimed that the data in the monitoring equipment was not part of the medical record and that the strips were printed out after the patient's death by risk management. Lower courts agreed with the hospital. However, the state Supreme Court ruled that a patient's medical record consists of all data a healthcare provider decides to keep that is generated in the process of the patient's healthcare treatment and pertains to the patient 's medica l history, diagnosis or medical condition, regardless of where the data is stored. The focus, according to the Supreme Court, is whether a healthcare provider decided to maintain the data. Although this ruling involved hospital records, it also likely applies to an individual practitioner's records. The good news is that the ruling does not significantly broaden the definition of "medica l record" to include "everything having to do with a patient." Nor does it enlarge your duty to maintain information you do not already keep in the normal course of business. But perhaps most importantly, it does not eliminate your discretion to determine what patient data to maintain. Ever since lawmakers began tightening the cloak of protection around peer-review and risk- management records, plainti–s have been looking for loopholes. The Supreme Court's decision invites arguments that all information maintained by a healthcare provider is a medical record, regardless of the purpose for which it is maintained. Thus, an important factor in determining whether a patient can obtain a document will be whether you, as the healthcare practitioner, decide to maintain a par- ticular document "in the process of the patient's health care treatment." So what does this mean for your practice? You should have a clear and consistent understanding within your o˜ce as to what medical information to maintain for each patient. Moreover, if records are maintained in more than one location, your sta– needs to know where to retrieve them if requested. If you are not sure what information to maintain, consult your legal counsel who can hopefully keep the war away from your castle. Justin Greenfelder is an attorney with Buckingham, Doolittle & Burroughs, LLC and a member of its Health & Medicine, Litigation, and Business Practice groups. He is a partner in Buckingham's Canton o™ce. For more information about the law firm, visit bdblaw.com or email Greenfelder at JGreenfelder@bdblaw.com. ■ The Medical Records War: What Does it Mean for Your Practice? BY JUSTIN S. GREENFELDER, ESQ. 1 2