The existing original medical records are inconsistent with the copy records submitted by the hospital to the court, and it is unreasonable for the hospital to make an explanation that the medical records are modified for perfection and the contents of the medical records are not substantially different. Therefore, it is determined that the hospital has tampered with the medical records, and it is presumed that the hospital is at fault for the damage results to patients. Medical institutions and their medical staff shall fill in and properly keep medical records such as hospitalization records, doctor's orders, inspection reports, operation and anesthesia records, pathological data, nursing records and medical expenses in accordance with the regulations. Medical records refer to the sum of words, symbols, charts, images, slices and other materials formed by medical personnel in the process of medical activities, including outpatient (emergency) medical records and hospitalization medical records. Medical record writing refers to the behavior of medical staff to obtain relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, treatment and nursing, and to summarize, analyze and sort out the records of medical activities. The writing of medical records should be objective, true, accurate, timely, complete and standardized. When there is a typo in the process of medical record writing, it should be marked with double lines on the typo, and the original record should be kept clear and identifiable, and the time of revision should be indicated, and the signature of the reviser should be made. Scraping, gluing, painting and other methods shall not be used to cover up or remove the original handwriting. Medical staff at higher levels have the responsibility to review and modify the medical records written by medical staff at lower levels.

Legal basis:

Regulations on the Management of Medical Records of Medical Institutions

Article 17 A medical institution shall accept the applications of the following persons and institutions for copying or consulting medical records, and provide medical records copying or consulting services according to regulations:

(1) The patient himself or his entrusted agent;

(2) the legal heir of the deceased patient or his agent.

article 18 a medical institution shall designate a department or full-time (part-time) staff to be responsible for accepting applications for copying medical records. When accepting an application, the applicant shall be required to provide relevant certification materials, and the form of the application materials shall be reviewed.

(1) If the applicant is the patient himself, he shall provide his valid identity certificate;

(2) if the applicant is a patient's agent, it shall provide the valid identification of the patient and his agent, as well as the legal certification materials and power of attorney of the agency relationship between the agent and the patient;

(3) if the applicant is the legal heir of the deceased patient, it shall provide the death certificate of the deceased patient, the valid identity certificate of the legal heir of the deceased patient, and the legal proof of the relationship between the deceased patient and the legal heir;

(4) if the applicant is the agent of the legal heir of the deceased patient, it shall provide the death certificate of the patient, the valid identity certificate of the legal heir of the deceased patient and his agent, the legal proof of the relationship between the deceased patient and the legal heir, the legal proof of the agency relationship between the agent and the legal heir and the power of attorney.

Article 19 A medical institution may copy the temperature list, doctor's advice list, hospitalization record (admission record), operation consent, anesthesia consent, anesthesia record, operation record, nursing record of seriously ill (critically ill) patients, discharge record, informed consent for blood transfusion treatment, consent for special examination (special treatment), pathological report and inspection report for the applicant.