1. How to handle medical accident data

Sealing medical records is the legal right of the patient. When a dispute occurs, the patient can request that medical records be sealed. Article 8 of the "Regulations on the Handling of Medical Accidents" stipulates: "Medical institutions shall write and properly keep medical records in accordance with the requirements stipulated by the health administrative department of the State Council. If they fail to write medical records in time due to rescuing critical patients, the relevant medical personnel shall Make additional records according to the facts within 6 hours after the end, and make an annotation. "Article 16 of the "Regulations on Handling Medical Accidents" stipulates: "When a medical accident dispute occurs, the discussion records of fatal cases, the discussion records of difficult cases, and the superior physician's ward rounds records. , consultation opinions and disease course records should be sealed and unsealed in the presence of both doctors and patients. The sealed medical record information can be a copy and kept by the medical institution. ”

2. How to determine the authenticity of medical records

Before medical records and other medical documents can become evidence to determine the facts of a case, they must first be cross-examined by both parties in court, and the authenticity of the medical records can be determined through cross-examination. The specific requirements for cross-examination are as follows.

First, the form and format of the medical records should be cross-examined. The writing of medical records should comply with the requirements of the "Basic Standards for Writing Medical Records" issued by the Ministry of Health, including the completeness of medical records, correction methods for writing errors, approval methods by superior physicians, physician signatures, etc. Article 6 of the "Basic Standards for Writing Medical Records (Trial)" stipulates that when typos occur during the writing process of medical records, double lines should be used to mark the typos, and methods such as scraping, gluing, and smearing should not be used to cover up or remove the original handwriting.

Secondly, the contents of the medical records should be cross-examined. Pay attention to whether the content of the medical record is consistent and conforms to the laws of disease occurrence, development, and evolution.

Finally, verify the medical records with other evidence. Medical records are important as key evidence, but if they are not the only evidence, there may be other evidence in the lawsuit. Therefore, during court cross-examination and judge review and determination, attention must be paid to mutual corroboration with other evidence to eliminate contradictions and inconsistencies.

3. Contents of medical orders

For medical instructions issued by doctors during medical activities, the doctor collects a detailed medical history, carefully conducts a physical examination and conducts necessary imaging and laboratory tests, and conducts them in a timely manner. The first course of illness is recorded and medical records are written, and issued after the preliminary diagnosis is made. Medical instructions include: nursing routine, level of care, diet type, body position, various examinations and treatments, drug names, dosages and usage. The content of the medical order and the start and stop times should be written by the physician. The contents of medical orders should be accurate and clear. Each medical order should contain only one content and indicate the time of issuance, which should be specific to the minute. Doctor's orders may not be altered.

When cancellation is required, the word "cancel" should be marked in red ink and signed. Generally, physicians are not allowed to give oral medical orders. When oral medical orders need to be given to rescue critical patients, the nurse should repeat them. After the rescue, the doctor should immediately make up the medical instructions according to the facts. Medical orders are divided into long-term medical orders and temporary medical orders. The content of the long-term medical order includes the patient's name, department, hospitalization record number (or medical record number), page number, start date and time, content of the long-term medical order, stop date and time, physician's signature, execution time, and execution nurse's signature.