The discussion on the revision of medical records has never stopped in hospitals, because in actual work, there are almost no hospitals that do not revise medical records. Especially before the hospital evaluation activities, in order to achieve the ideal first-class medical record rate, the repair rate of individual hospital medical records reached 100%. Disorderly revision cannot guarantee the quality of medical records.

Allow real modification of medical records within the prescribed time limit. In recent years, a large number of lawsuits have appeared because the contents of medical records are found to be inconsistent with the actual situation of diagnosis and treatment. Patients may not know the right or wrong of medical technical problems, but because they are personally treated, they understand the basic process.

Therefore, when patients have doubts about medical services and find that the records are inconsistent with the facts through copying and checking medical records, patients and their families will turn the pain of suffering the consequences of treatment damage into anger of finding that doctors' records are inaccurate, and most medical disputes will escalate into lawsuits. Reasonable modification of Hony's in-patient medical records is allowed.

Permission to modify medical records is supported by industry documents. The Basic Specification for Medical Record Writing is the first compulsory working document on medical record writing issued by the Ministry of Health, in which Articles 7 and 8 respectively stipulate: "Medical records written by interns and interns shall be reviewed, revised and signed by medical personnel who are legally practicing in this medical institution.

The document "It is the responsibility of superior medical staff to review and modify the medical records written by lower medical staff" also stipulates that the correction of typos should draw double lines on the typos, and the original handwriting should not be covered or removed by scraping, gluing or painting. It can be seen that it is allowed to modify the medical record. However, if there is a text error related to the writing level in the process of writing the medical record, it is allowed to correct the file.

Such as typos, typos, missing words, unreasonable sentences, punctuation marks, missing page numbers, etc. For example, if you write a net, the patient should become the correct king. Recording errors sometimes occur in men and women, left and right, up and down, etc. For example, left ovarian disease.

The left lesion was surgically removed, and the medical record was wrongly written as the right. Because the right lesion was not treated as the left lesion during treatment, the wrong written expression can be modified. Hongyi violated the standard to modify the medical record! Irregular revision of medical records that violate the norms.

How to punish those who forge, conceal or destroy medical records? Those who alter, forge, conceal or destroy medical records shall be ordered by the administrative department of health to make corrections and given a warning; The responsible person in charge and other directly responsible personnel shall be given administrative sanctions or disciplinary sanctions according to law; The circumstances are serious.

Its practice certificate or qualification certificate shall be revoked by the original issuing department. In the quality inspection of medical records, we found that many modifications were not only beyond the scope of literal errors, but also far from the actual clinical diagnosis and treatment, including the signs that were ignored when they were admitted to hospital.

Blood pressure was not measured for the patient, but blood pressure data was available, and the injury during treatment was not diagnosed or recorded in the medical record; The director is away on business, but there is a record of the director's rounds and so on. Modifying the problems of patients who have already been treated is considered tampering. Medical records are very important for the whole medical damage compensation case.

Altering, forging, concealing or destroying medical records, interfering with and affecting the identification of medical accidents, resulting in adverse consequences. It is undoubtedly illegal to modify medical records in order to cover up medical behavior mistakes. Evidence of causal relationship between medical behavior and damage results, in this case.

The hospital falsifies evidence to prove that there is no causal relationship between medical behavior and damage results, and the medical records are contradictory or obviously wrong, and the medical record keeper or controller gives evidence or makes a reasonable explanation; If the authenticity cannot be confirmed, it is not conducive to the preservation or control of medical records. If the medical record is indeed changed, the parties claim that the change will not affect the substantive content of the medical record.

The burden of proof should not affect the substance of medical records. There is a causal relationship between the wrong behavior of modifying medical records and the damage, and it is necessary to judge the responsibility due to the presumption of fault. According to the provisions of the Basic Specification for Medical Record Writing (Trial), medical records can be modified. Specific conditions and requirements include.

When typos appear in the process of writing medical records, they should be marked with double lines, and the original handwriting should not be covered or removed by scraping, gluing or painting. Medical records shall be written in accordance with the provisions and signed by the corresponding personnel; Medical records written by interns and trainee medical personnel shall be audited by medical personnel who are legally practicing in this medical institution.

Modify and sign; The superior medical staff has the responsibility to review and modify the medical records written by the lower medical staff; In case of revision, the date of revision shall be indicated and signed by the reviser, and the original records shall be kept clear and legible. Article 9 of the Regulations stipulates that it is strictly forbidden to alter or forge medical records. Do not belong to the above modification.

It should be considered as tampering. If the doctor's "modification" of the medical record is identified as "tampering" by the court, it cannot be used as the basis for identification. The medical side will be unable to provide evidence because of tampering with medical records, and the court can directly judge the medical side to lose the case according to the rules of evidence. According to the provisions of "Electronic Medical Record Application Management Standard (Trial)".

After the medical personnel log in to the electronic medical record system through identity identification to complete the writing, review and modification operations and confirm, the system should display the medical personnel's name and completion time. Moreover, electronic medical records shall not be modified in principle after filing. Under special circumstances, if it is really necessary to modify it, it shall be approved by the medical department of the medical institution and the traces of modification shall be kept.

In practice, we should also keep the procedures recognized by the medical department to avoid putting ourselves at a disadvantage because we can't provide evidence in litigation. The basic requirement of Hony's medical record revision is that the principles and methods of medical record revision must be managed and controlled, and a clear revision method is the premise of standardizing the management of medical record revision.

The revision of medical records must be limited in content and time, and must be carried out on the basis of certain conditions and principles.

Specific details are suggested for discussion in the industry. The following are the basic requirements that should be met:

First, medical staff must objectively record all medical services such as patient examination, treatment and nursing, including diagnosis ideas, treatment plan implementation, effect observation, communication between diagnosis and treatment plan and informed consent of patients, changes and outcomes of patients' condition, etc. There is an error in this part.

It is not allowed to modify directly or draw a double horizontal line to modify. People should be able to see when and how the error occurred, the reasons and responsibilities, whether the superior doctor checked, whether the problem was found, handled and remedied in time and effectively, and whether the competent department was dereliction of duty.

Second, modification is allowed, but tampering and forgery are strictly prohibited. Special emphasis should be placed on recording according to the actual clinical work, and all clinical behaviors of medical staff, including examination, diagnosis, treatment and nursing, should be recorded as they do.

Third, there must be a final time limit for modifying medical records. Whatever the reason, regardless of the quality of the medical records, after the patient is discharged from the hospital and the medical records are sent to the medical records inventory file, the inpatient medical records will become medical records, which should be kept as they are and cannot be modified.