1, the form and format of medical records should be questioned. The writing of medical records should meet the requirements of the Basic Specification for Medical Records Writing promulgated by the Ministry of Health, including the completeness of medical records, the correction methods of writing errors, the examination and approval methods of superior doctors, and the signature of doctors. According to the relevant laws and regulations, when there are typos 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.

2. The contents in the medical records shall be cross-examined. Pay attention to whether the contents of medical records are consistent and conform to the law of disease occurrence, development and evolution.

3, medical records and other evidence confirmed. As key evidence, medical records are very important. If it is not the only evidence, there may be other evidence in the lawsuit. Therefore, when the court cross-examines and judges examine, we must pay attention to mutual confirmation with other evidence to eliminate contradictions and inconsistencies.

Whether there are special problems such as forgery and tampering in medical records can be identified by judicial authentication institutions and opinions can be obtained. The people's court may also inquire from professional institutions ex officio. If it is impossible to determine whether it materially affects the authenticity and integrity of medical records, it shall apply for relevant appraisal, instead of raising objections, so that the appraisal of the whole case cannot be carried out.

The correct way to modify medical records is as follows:

1. In case of typos in the process of writing medical records, double lines shall be used to mark the typos, and the original records shall be kept clear and readable, with the revision time indicated and signed by the reviser.

2. Scraping, gluing and painting are not allowed to cover up or remove the original handwriting.

3, the superior medical staff have the responsibility to review and modify the medical records written by the lower medical staff.

To sum up, medical records and other medical documents must first be cross-examined by both parties in court before they can become evidence to determine the facts of the case, and the authenticity of medical records can be determined through cross-examination.

Legal basis:

People's Republic of China (PRC) China Physician Law

Article 24

When implementing medical, preventive and health care measures and signing relevant medical certificates, doctors must personally check and investigate, and fill in medical documents such as medical records in time according to regulations, and may not conceal, forge, tamper with or destroy medical documents such as medical records and related materials without authorization.