after a medical dispute, the patient's friends will actively try to fix the evidence that the medical institution is at fault. The first thing that comes to mind is to seal and copy the medical records. However, when they ask the medical institution, they find that the hospital medical records are not written, or they deliberately delay because they are not written, so what should the patient do? First, the common situation of not recording medical records. 1. Private clinics do not record medical records. It can be said that 9% of private clinics don't record medical records, whether it's medical records, treatment records or nursing records, they don't even have prescriptions. It's not that the law doesn't stipulate that clinics don't have to record medical records, but because they don't have such a habit, and many regional health and health committees take a laissez-faire attitude towards the medical record writing of these small medical institutions, as long as they record medical records, but in fact, this log doesn't reflect the diagnosis and treatment process, and it won't be taken away by patients, so it can't be called legal. 2. Dental clinics and hospitals do not record medical records. Most dental clinics and even hospitals don't record dental medical records, and some may have a folder in the computer to save patients' dental films and treatment plans, but they don't record medical records according to regulations. Many patients can't find medical records to record the situation before treatment after disputes, such as gingival atrophy, periodontitis, alveolar bone absorption, etc., so it is not known whether this treatment has caused damage. 3. Follow-up visits do not record medical records. This common problem exists in both clinics and hospitals. Patients do not record medical records during follow-up visits, such as dressing change of surgical wounds, examination results, simple prescription of drugs, etc., which brings hidden dangers to these simple problems, such as wound dehiscence and infection, misdiagnosis and missed diagnosis in examinations, and side effects of drugs not observed, etc. Therefore, even the simplest diagnosis and treatment process, medical records should be recorded. 4. The medical record management in some private hospitals is not standardized. Some private hospitals put interests first, and then write medical records, even after treatment. Lawyer Lin encountered several such situations. After a serious medical dispute occurred in private hospitals, he asked lawyer Lin to handle it and give guidance on how to avoid responsibility. When lawyer Lin went there, he found that the operation had been done for a few days, but he didn't write a word of medical records or even a consent form for the operation. Another one had an anesthesia accident during the operation, and it turned out that the surgeon brought friends privately. This serious loophole in medical record management has great medical risks. 5. Medical beauty hospitals do not write medical records. Many medical cosmetology hospitals, especially in Light medical cosmetology, don't write medical records. They think that this kind of treatment has little risk, simple operation and no record, but once a dispute occurs, they have to make it up temporarily. There are also some medical beauty treatments that are operated by unqualified doctors, because they dare not write medical records without qualifications, and qualified doctors are unwilling to sign them, which leads to the lack of medical records. Lawyer Lin often sees this situation of needing qualified doctors to supplement medical records afterwards. Second, what should I do if I don't write a medical record? 1. Not writing medical records is not a bad thing for patients to protect their rights. It must be the fault of the medical institution not to write the medical record. Without the medical record, the judicial appraisal or medical malpractice appraisal may not be completed, and this adverse consequence will be borne by the medical institution. If legal procedures are taken, the court will often judge the medical institution to bear part or all of the responsibility. 2. Find a way to fix the fact that the hospital didn't write medical records. At the beginning of the dispute, general medical institutions will admit that they didn't write medical records. At this time, patients should pay more attention to this evidence, and they can fix it by audio and video recording, or by WeChat or SMS. For example, why didn't they write medical records at that time? Now there is not even a record. If the evidence is not fixed in time, medical institutions may no longer admit that they have not written medical records when administrative agencies intervene or conduct appraisal. They will either say that the medical records have been written to the patients or make up the medical records, and the patients will be passive at this time. 3. What should I do if the hospital doesn't admit that it didn't write a medical record? For outpatient medical records, it is really passive if the hospital says that it has been recorded and handed over to the patient, because according to the relevant regulations on medical record keeping, outpatient medical records are kept by the patient, and it is difficult to leave evidence when the hospital did not give them and the patient did not ask for them, so it is difficult for the patient to prove afterwards that the hospital did not give them to the outpatient medical records at that time. In this case, you can ask the hospital to take the surveillance video when you see a doctor. Generally, there is surveillance in the consultation room corridor, and there is surveillance in many consultation rooms. Of course, the hospital will not cooperate with it, but its behavior can be inferred that the medical record was not given at that time and the hospital did not cooperate with it. Then you can put forward a formal request-seal the surveillance video. If the hospital still does not cooperate, or find reasons to say that the surveillance is bad and has been covered, you can apply to the public security organ or the court for it. What should the hospital do if it doesn't admit that it didn't write the medical record and make up the record afterwards? It is difficult to prove that the hospital makes up the medical records afterwards. If the medical records are written through the electronic medical record system, it can be required to seal the electronic medical records and retrieve the background logs formed by the electronic medical records, which can completely prove the behavior of making up the records. If the medical records are recorded by computer electronic files, the writing logs can also be sealed and retrieved; If the medical record is handwritten, only the handwriting and the time of the document can be identified. Generally, the court or a third party agency entrusts the corresponding identification agency to identify it. Third, what should I do after the evidence of not writing medical records is fixed? 1. The medical record involves the main diagnosis and treatment process. If unwritten medical records are the main diagnosis and treatment process that leads to medical damage, it is basically impossible to carry out judicial appraisal or medical malpractice appraisal. Then, if we insist on safeguarding rights from unwritten medical records, there will be a great chance of winning. Whether it is negotiation or litigation, the balance of victory will tend to the affected party. 2. There are other data that can restore the diagnosis and treatment process. After medical disputes are brought to court, almost all judges are only willing to make judgments based on the conclusion of judicial expertise, so even if the medical records are defective, they will actively mobilize the patients to make judicial expertise. If the hospital does not write medical records, but there are prescriptions, examination results and treatment lists that can basically restore the treatment process, it is not recommended to stick to the unwritten medical records as the starting point for safeguarding rights, because at this time, the defects of medical records are no longer the reason for the failure of appraisal. It is too ideal for the court to judge the medical institutions to bear the adverse consequences simply because the medical records are defective. Lawyer Lin suggested that it is better to listen to the court. 3. unwritten medical records are not the main diagnosis and treatment process. If the unwritten medical record is not the diagnosis and treatment process that leads to medical damage, or the medical institution is not at fault in the diagnosis and treatment process, for example, the hospital did not write the emergency medical record when the patient was admitted to the emergency department, and the damage was caused by improper operation after admission, at this time, it is basically impossible to sue the court and ask the court to apply the principle of presumption of fault to judge the hospital compensation. Although many judges are not very professional in handling medical disputes, they will still have a clear understanding of the basic facts, and they will have a simple thinking-just because they have not written emergency medical records, they will be required to bear all the compensation responsibilities? It's not like the operation was done in the emergency department. Therefore, in this case, Mr. Lin does not suggest insisting on defending rights based on unwritten medical records, or listening to the opinions of the court for judicial appraisal. 4. What if I don't want to go through legal procedures? After mastering the evidence that medical institutions have not written medical records, many patients still don't want to go through legal procedures. Is there any way to protect their rights? Of course, you can complain to the Health and Health Commission and ask for a written reply. This written reply can not only allow you to continue to defend your rights from a moral high point, such as media exposure and on-site rights protection, but also be used as evidence to sue the court after negotiation fails. The judge will use this written reply or handling decision as a good basis for hearing cases, such as adopting the patient's claim not to conduct judicial expertise, or judging the hospital to bear part of the responsibility when there is no expert conclusion, or increasing the hospital's liability for compensation on the basis of expert opinions. In a word, the administrative agency's handling of unwritten medical records in hospitals can bring great help to the later rights protection. Of course, there is a situation that can't be ruled out. A few private medical institutions are broken after being punished by administrative punishment, and no longer negotiate compensation with patients. Therefore, it is better to defend rights before soldiers. In short, it is the fault of the medical institution not to write the medical record. If this fact can be fixed to the evidence, it will be beneficial to the patient. I hope the above views will be useful to the patient's friends. February 23, 222