note! Electronic medical record overdue modification illegal

[Directory] The electronic medical record is not something you want to change, you can change it casually. Beware of the prohibition of the law, it is recognized as a correction, forgery of medical records, and it will become a pain that medical institutions can never erase.

With the continuous development of national computer network information technology, electronic medical records have emerged as the times require, and have been widely used in clinical practice. Compared with the traditional handwritten medical history, the writing of electronic medical records has greatly improved the office of the hospital. Efficiency, but new problems that come with it continue to emerge. China’s laws stipulate that it is strictly forbidden to alter or forge medical records. Does this law apply to electronic medical records? Do you know the background data of the electronic medical record? What kind of operation will be identified as a correction, forgery of medical records?

To answer this series of questions, we start with a recent medical dispute case, the case is like this:

July 10, 2017 patient Wang Because of “chest stuffiness” to a well-known top three hospital in Shanghai, the doctor told him that surgery was needed. On July 13, Wang once again went to the special needs clinic of the hospital. The doctor thought that it was a severe regurgitation of the mitral valve and was admitted to hospital. At 12 o’clock on July 17th, the patient was admitted to the operating room. At 11 o’clock in the evening, the operation was completed. The patient was admitted to the intensive care unit and the patient died at 2 am on July 18.

The contradiction between doctors and patients was born. After many unsuccessful negotiations, the family members of the patient finally sue the hospital into the court. The court organized the two parties to open the trial. In the evidence-based section, the patient discovered the problem because In the medical history, I found two “visiting records before anesthesia”. The conclusion is completely the opposite. One page writes “high risk” and one page writes “low risk”. How can there be two pages of completely opposite information in the medical history?

The patient’s family then used this as evidence to submit an application for electronic medical record data identification. The court commissioned a third-party authority to initiate an electronic medical record data identification procedure when the reasons were sufficient. . The final judicial appraisal results show that Wang’s medical records have been revised 76 times in total. Among them, the death time “2017-07-18 02:15” after the hospital’s “to the attending doctor’s investigation record, death record, rescue record, chief physician check The room record, the first post-operative course record, the first course record, the first visit to the chief physician, the preoperative summary, discussion, surgical record, and course record were all modified.

In 2010, China began to implement the “Basic Norms for Medical Record Writing”. In 2017, the “Electronic Medical Record Application Management Regulations (Trial)” was implemented. What is the relationship between these two laws? Some people will talk to Shao, the electronic medical record does not stipulate the time for writing various medical records, so there is no time requirement, as long as there is no filing, you can modify it at will. Is that true?

Please remember, there is only one answer: wrong! Blunder! Wrong!

Article 7 of the “Electronic Medical Record Application Management Regulations (Trial)” stipulates that “Basic Specifications for Medical Record Writing” applies to electronic medical record management, that is to say, the writing of electronic medical records is still based on the basic norms written by traditional medical records. Strict requirements, for example: the first course record should be completed within 8 hours after the patient is admitted to the hospital. If the rescue record is not timely written due to the rescue of the critically ill patient, it should be recorded in the 6 hours after the end of the rescue, and so on.

The biggest feature of the electronic medical record is that it is “full trace”. No matter when you make any changes, the current technical means can be monitored from the background data. Just like the case mentioned above, every time the background changes the record, including the time, the content, the operator is mercilessly recorded by the computer. This is a typical act of forgery and falsification of medical history. Even if the hospital is not at fault, all the modifications are typos, and the case will undoubtedly be presumed by the court to be a fault of the medical institution.

At this point, Shao lawyers should remind medical institutions that the writing of electronic medical records should follow the principles of objectivity, truthfulness, accuracy, timeliness, integrity and standardization. It is strictly forbidden to modify the period, just like the case where the patient has died after the death of the patient. How do you explain that this is not a falsification of the medical record?

Our law stipulates that medical institutions and their related personnel are strictly prohibited from altering or forging medical records. It can be seen that the uncorrected and forged medical records are the statutory duties of medical institutions and their related personnel. According to the provisions of China’s Tort Liability Law, “falsing and falsifying medical history data” can presume that there is a fault in medical institutions and apply the principle of presumption of fault. The law stipulates that the patient is injured in the medical treatment activities, and if the medical institution and its medical personnel are at fault, the medical institution shall be liable for medical damages.

So, please remember, don’t arbitrarily modify the electronic medical record, otherwise it will cause serious legal consequences.

【Author: Shao Yingfang Beijing Pacific Century (Shanghai) senior partner of law firm]