OHIO - MEDICAL RECORDS

What is considered a patient’s medical record?

A medical record is any document that pertains to a patient’s medical history, diagnosis, prognosis, or medical condition and is generated in the process of health care treatment.

R.C. 3701.74(A)(2)

How long must a physician retain medical records?

Ohio statutes do not specifically address a physician’s duty to retain medical records. However, licensed health facilities must maintain medical records for at least 6 years from the date of discharge.

OAC 3701-83-11(E)

It has been suggested by the medical board that physicians retain their records for at least the same period of time, 6 years.

How should a physician maintain his or her medical records?

The Ohio State Medical Association has published the following guidelines to assist physician record keeping:

(a) Record the complete date (month, day, year) on each record entry;

(b) Sign each entry with the name, title, and position of the medical staff making the entry;

(c) Record the patient’s identification number on each page of the chart;

(d) Use permanent ink and write legibly;

(e) Each entry should include: the mode of patient contact, the reason for contact, any information or treatment given to the patient, and plans for future care or follow-up;

(f) Review and initial all notes made by a non-physician;

(g) Conspicuously display all patient allergies or contraindications;

(h) Document disclosures of informed consent; and

(i) Document all patient instructions or materials given.

What right does a patient have to access medical records?

The law does not directly address patient access to records kept by a private physician; however, the American Medical Association (AMA) has stated that all medical records should be made available to patients upon proper request. Such medical records should not be withheld for a patient’s failure to pay for medical services.

AMA Op. 7.01

May physicians charge patient fees for copying medical records?

Ohio law does not directly address the issue of charging patients fees for accessing their medical records. However, the AMA has stated that physicians may charge a reasonable fee for copying services.

AMA Op. 7.02.

What is the confidential nature of patient medical records?

A patient’s medical record is a confidential document that should not be communicated to a third-party without the patient’s consent. A physician may be disciplined for breaching this confidentiality.

RC 4731.22(B)(4)

However, in some cases, medical records may be disclosed when:

(a) Reporting a crime under RC 2921.22;

(b) Reporting communicable diseases under OAC 3701-3-01;

(c) Reporting vital statistics under OAC 3701-5;

(d) Reporting child or elder abuse under RC 2151.421; or

(e) Responding to a subpoena issued by the Medical Board.

What should be done with medical records when a practitioner dies or sells or leaves a medical practice?

Ohio law does not specifically address what steps a practitioner must take when leaving a medical practice. However, according to the AMA, a physician should notify patients when the practitioner is leaving a group practice.

AMA Op. 7.03

Further, a physician selling his practice or the estate of a deceased physician may transfer the physician’s medical records if (a) all active patients are notified that the records are being transferred to another physician, and (b)all patients are given the right to have their records transferred to another physician of their choice.

AMA Op. 7.04

Copyright © Kern Augustine Conroy and Schoppmann, P.C. Used with permission.

Updated 2008