The difference between medical record modification and falsification, and the difference between med

The main differences between medical record modification and falsification are as follows:

1. Different in nature

It is legal to revise medical records, because Articles 7 and 8 of the Basic Standards for Writing Medical Records stipulate that "medical records written by medical interns and probationary medical personnel shall be reviewed, revised and signed by medical personnel who are legally practicing in their medical institutions." "The superior medical staff has the responsibility to review and revise the medical records written by the junior medical staff.

So it is legal to amend the medical record.

It is illegal to falsify medical records. According to Article 58, Article (2) of the Regulations on the Handling of Medical Accidents: Altering, falsifying, concealing, or destroying medical records. The health administrative department shall order corrections and give warnings.

2. The meaning is different:

Amending a medical record means modifying something in a medical record; Falsification of medical records is the complete creation of some false cases, which is purely fake.

3. Reliability is different:

Modifying the medical record is only to modify some content on the original case, which has a certain degree of authenticity; Falsified medical records are completely fake, and the authenticity is very low.

The difference between legal and illegal.

It is illegal to issue false medical records and certificates, or to buy, sell or use forged or altered official documents, certificates, or certification documents of state organs, people's organizations, enterprises, public institutions, or other organizations; It is illegal to buy, sell or use false certificates. According to Article 37 of the Law on Medical Practitioners, if a physician signs a diagnosis, epidemiology, epidemiology and other supporting documents or related to birth and death without personally examining and investigating in his or her professional activities, the people's health administrative department at or above the county level shall give a warning or order him to suspend his practice activities for not less than 6 months but not more than 1 year; where the circumstances are serious, their practice certificates are revoked; where a crime is constituted, criminal responsibility is pursued in accordance with law.

Article 37 of the Law on Medical Practitioners stipulates that if a physician signs a diagnosis, epidemiology, epidemiology or other certification documents or related birth and death certificates in his or her practice activities without personally examining and investigating, he shall be given a warning or ordered to suspend his practice activities for not less than 6 months but not more than 1 year by the people's health administrative department at or above the county level; where the circumstances are serious, their practice certificates are revoked; where a crime is constituted, criminal responsibility is pursued in accordance with law.

Legal analysis: (1) The nature is different: it is legal to modify medical records, but it is illegal to tamper with medical records; (2) Different reliability: the modified medical record is only modified on the original medical record, which has a certain degree of authenticity, and the tampered medical record is A, and the authenticity is very low.

Legal basis: Article 1222 of the Civil Code of the People's Republic of China: In any of the following circumstances, the medical institution is presumed to be at fault if a patient suffers harm in the course of diagnosis and treatment: (1) violating laws, administrative regulations, rules, and other provisions related to diagnosis and treatment norms; (2) Concealing or refusing to provide medical records related to the dispute; (3) Loss, falsification, alteration, or unlawful destruction of medical records.

Legal Analysis: 1. Erroneous records of time in medical records generally cannot be found to be forgery or tampering with medical records.

For the erroneous record of time, such as the time of discharge, the time of surgery, the time of anesthesia, and the time of other medical measures, although there is a discrepancy between the recorded time and the facts, there are usually other records that can corroborate the correct time, which does not conform to the general common sense of artificial fraud, if it can be falsified, all relevant time records in the medical record should be changed to maintain relative consistency, and for these problems, once the patient raises them, the medical institution often admits the facts stated by the other party in court. Therefore, the flaws in such medical records generally cannot be used as the basis for determining that medical institutions have forged or tampered with medical records.

2. Time records affect the evaluation of medical behavior, and may be considered as falsification or falsification of medical records.

If the relevant time records affect the judgment of the appropriateness of the medical act, and the medical institution denies the objection raised by the patient, and the objection is later verified to be sustained, the facts of the case should be comprehensively considered to determine whether it can be the basis for the medical institution to falsify or tamper with the medical records.

3. Some of the differences in time records are subjective judgments, and cannot be used as a basis for improper conduct by medical institutions.

For example, the length of the operation and the time of the onset of related symptoms are difficult for the plaintiff to determine that the defendant's conduct was improper.

Violations of medical record writing norms may be used as evidence of medical establishments' improper conduct in writing medical records, but whether it reaches the level of proof for determining the forgery or falsification of medical records should be comprehensively considered in light of the circumstances of the case.

4. Common violations of medical record writing norms and legal consequences.

There is an act of using scraping, sticking, painting, etc., to cover up or remove the original handwriting. This type of conduct is an act that is clearly prohibited in the relevant medical record writing specifications, and the conduct may objectively lead to the indecipherability of the original handwriting, that is, the truth of the relevant facts cannot be ascertained, so it can be supported that the conduct of the medical institution is improper, but whether it can be inferred that the medical institution has forged or tampered with medical records on this basis should be comprehensively considered in light of the specific circumstances of the case. and bear the civil liability for compensation; In some cases, it can only be determined that the medical record is not written in a standardized manner, and the health administrative department will punish the relevant behavior.

Legal basis: Civil Code of the People's Republic of China

Article 1218: Where a patient suffers damage in the course of diagnosis and treatment, and the medical establishment or its medical staff is at fault, the medical establishment is liable for compensation.

Article 1222: In any of the following circumstances, the medical institution is presumed to be at fault if a patient suffers harm in the course of diagnosis and treatment:

1) Violating laws, administrative regulations, rules, and other provisions related to diagnosis and treatment norms;

(2) Concealing or refusing to provide medical records related to the dispute;

(3) Loss, falsification, alteration, or unlawful destruction of medical records.

Legal analysis: In a medical malpractice case, the patient can prove that the hospital concealed or refused to provide medical records related to the dispute; If the hospital falsifies, falsifies or destroys medical records, the court will directly presume that the medical institution is at fault and bear the liability for compensation. As evidence, medical records must meet the requirements of authenticity, legitimacy and relevance.

The determination of "falsification or falsification of medical records" is not a denial of the authenticity of the evidence in medical records. As long as the medical records of the parties are provided from the hospital, they meet the requirements of authenticity and relevance of the evidence. The so-called "falsification or falsification of medical records" is only the determination of whether there is forgery or falsification of medical records in the diagnosis and treatment of medical institutions.

The act "shall include the determination of the written form of the medical record and the determination of the substance." "The act" can be determined with the help of expert witnesses to assist in the determination or judicial appraisal.

Legal basis: Article 1222 of the Civil Code of the People's Republic of China Where a patient suffers damage in the course of diagnosis and treatment and has any of the following circumstances, the medical institution is presumed to be at fault:

1) Violating laws, administrative regulations, rules, and other provisions related to diagnosis and treatment;

(2) Concealing or refusing to provide medical records related to the dispute;

(3) Loss, falsification, alteration, or unlawful destruction of medical records.

Legal analysis: (1) The nature is different: it is legal to modify medical records, but it is illegal to tamper with medical records; (2) Different reliability: the modified medical record is only modified on the original medical record, which has a certain degree of authenticity, and the residual and tampered medical record is A, and the authenticity is very low.

Legal basis: Article 1222 of the Civil Code of the People's Republic of China: In any of the following circumstances, the medical institution shall be presumed to be at fault if the patient suffers damage in the course of diagnosis and treatment: (1) violating the provisions of laws, administrative regulations, rules, and other relevant diagnosis and treatment norms; (2) Concealing or refusing to provide medical records related to the dispute; (3) Loss, falsification, alteration, or unlawful destruction of medical records.