If the medical record is inconsistent with the facts, the parties and their families can negotiate with the hospital and ask the hospital to make amendments. If the circumstances are serious, the parties and their families may report to the administrative department of health, which shall order them to make corrections and impose certain penalties.

Common specific situations in which medical records do not comply with laws and regulations are:

1, the important medical records are inconsistent with the facts and the contents of the records are contradictory;

2. Incomplete medical records may be hidden or destroyed;

3. The medical record has been altered, which may be forged or tampered with;

4. Not written or signed by the attending doctor or nurse;

5. There is a contradiction between the pathological section and the inspection report.

According to Chinese laws, patients have the right to copy or duplicate their outpatient medical records, inpatient medical records, temperature sheets, doctor's orders, laboratory tests (inspection reports), medical imaging examination data, special examination consent, operation consent, operation and anesthesia records, pathological data, nursing records and other medical records specified by the health administrative department of the State Council.

If a patient requests to copy or duplicate medical records in accordance with the provisions of the preceding paragraph, the medical institution shall provide copying or duplicating services, and affix the certification mark on the copied or duplicated medical records. When copying or duplicating medical records, patients should be present. The management of hospital medical records is stipulated by law and should be kept in the hospital to provide consulting services.

If the medical records are inconsistent with the facts, we can check all the medical records (generally including but not limited to one-day list/expense list, diagnosis certificate, hospitalization certificate, discharge certificate, home page of hospitalization medical records, admission records, course records, operation consent, anesthesia consent, informed consent for blood transfusion treatment, special examination (special treatment) consent, critical (severe) notice, doctor's advice, auxiliary examination report and temperature list.

If the medical institution is at fault, it will compensate the following items according to the degree of fault, but not necessarily the following items: including medical expenses, lost time, nursing expenses, transportation expenses, accommodation expenses, hospital food subsidies and necessary nutrition expenses. If the victim is disabled due to injury, it is also necessary to increase the disability compensation, the cost of disability AIDS, the living expenses of the dependents, and the necessary rehabilitation expenses, nursing expenses and follow-up treatment expenses actually incurred due to rehabilitation nursing and continuing treatment. The patient's medical records are kept by the hospital.

I hope the above content can help you. If in doubt, please consult a professional lawyer.

Legal basis: Article 1222 of the Civil Code of People's Republic of China (PRC).

If the patient is damaged in the diagnosis and treatment activities, it is presumed that the medical institution is at fault in any of the following circumstances:

(a) in violation of laws, administrative regulations, rules and other relevant medical norms;

(two) concealing or refusing to provide medical records related to the dispute;

(three) lost, forged, tampered with or illegally destroyed medical records.

Provisions on the management of medical records in medical institutions

Fifth medical institutions should establish and improve the medical record management system, set up a medical record management department or equip full-time (part-time) staff to be responsible for medical records and medical record management.

Medical institutions shall establish a system of regular inspection, evaluation and feedback on the quality of medical records. The medical department of a medical institution is responsible for the quality management of medical records.

Article 6 Medical institutions and their medical staff shall strictly protect patients' privacy and prohibit the use of patients' medical records for non-medical purposes, teaching and research.

Article 23 of the Law of People's Republic of China (PRC) on Medical Practitioners.

When implementing medical, preventive and health care measures and signing relevant medical certificates, doctors must personally check and investigate, and fill in medical documents in time according to regulations, and may not conceal, forge or destroy medical documents and related materials. Doctors shall not issue medical certificates that are irrelevant to their scope of practice or inconsistent with their categories of practice.

Article 26 of the Law of People's Republic of China (PRC) on Medical Practitioners.

Doctors should truthfully introduce the illness to patients or their families, but should pay attention to avoid bringing adverse consequences to patients. Doctors carrying out experimental clinical medical treatment shall obtain the consent of the hospital and the consent of the patients themselves or their families.