Legal analysis
The common formal defects include the wrong record of medical record number, name and ID number, the doctor's signature is not signed, only the intern's signature is not confirmed by the attending doctor, and the inpatient department records are wrong. For the defects of regular medical records, the general reason is that there are omissions in the management of medical record writing within the hospital, so it is necessary to ask for a separate cross-examination of the above suspicious medical records, and doctors should make a reasonable explanation for the above defects. If a reasonable explanation can be made, and the court finds that the defect has no direct impact on the substantive dispute in this case. If, after the doctor's explanation, the court thinks that the explanation is unreasonable and untenable, and there are still doubts about the authenticity of the relevant medical records, it shall exclude the relevant suspicious medical records during the appraisal, but it will not affect the authenticity of other flawless medical records. Common substantive defects, such as the authenticity of the signature of the patient or his family on the consent form for surgery, the revision of the diagnosis conclusion of the disease, and the doubts about the treatment plan or medication records. Because the authenticity of the above medical records is directly related to whether the hospital is at fault, such as whether it has fulfilled its obligation to inform, whether it has been misdiagnosed or mistreated, and whether it has used drugs improperly or wrongly. At this point, the people's court must clearly identify the authenticity of the medical records in combination with the evidence materials of the whole hospital.
legal ground
"General Principles of Civil Law of People's Republic of China (PRC)" Article 125 * * * 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 and nursing records. If the patient requests to consult and copy the medical records specified in the preceding paragraph, the medical institution shall provide them in time.