In addition to medical staff deliberately modifying and concealing medical records, there are other disputes caused by writing defects:
Informed consent, especially informed consent for surgery, is not signed by family members, which violates the right of informed consent.
Major disease changes were not informed in writing in time, which violated the right to know.
All kinds of mistakes in medical behavior records. For example, a medical behavior is recorded by multiple names, but individual medical behaviors are not recorded. The medical record is inconsistent with the actual medical behavior, and there are contradictory contents in the medical record. The inspection results do not correspond to the corresponding report forms and laboratory sheets. Some of these problems may be just clerical errors, and some will really have a substantial impact on the identification and confirmation of the facts of the case. No matter what the situation is, patients and their families will more or less doubt and distrust medical behavior.
Errors in case saving and classification. For example, the medical records are mixed with the medical records of other patients, and the contents of the medical records lack the items determined in the Basic Specification for Medical Records Writing (Trial). Although medical institutions generally explain that there are omissions in the binding process of medical records, patients think that medical institutions are deliberately concealing problematic medical records.
The diagnosis result is wrong. Medical institutions' misjudgment of illness is a substantial problem in medical record errors.
The mistake of tampering with medical records. The Basic Specification for Medical Record Writing (Trial) provides detailed regulations on the change of cases. "When typos appear in the writing process, they should be marked with double lines, and the original handwriting should not be covered or removed by scraping, gluing or painting." However, in the trial practice, the situation that does not meet the requirements of the norms is still widespread.
Qualification of producer of medical records. The Basic Specification for Medical Record Writing (Trial) stipulates that medical records written by interns and applicable medical personnel shall be reviewed, revised and signed by medical personnel who are legally practicing in this medical institution. However, in practice, we can see that the medical records written by the above two types of personnel have directly become medical records without being audited. Because this practice violates the provisions of Article 14 of the Law of People's Republic of China (PRC) on Medical Practitioners, it often becomes the main query object of patients.
The signature problem on the medical record. Include patient's signature and medical staff's signature. Regarding the signature of medical staff, some patients suggested that the signature was not signed by themselves, while others opposed the machine signature. ?
Doctor's advice.
Other issues.