(a) check whether the patient's signature is true. The law stipulates that patients have the right to know and choose, so patients will sign for confirmation when they receive surgical treatment, special examination and treatment. Therefore, when looking at the medical records, you must carefully check the patient's signature and apply for handwriting identification if necessary.
(2) Look at the formation time of medical records. If medical institutions tamper with, alter or forge medical records, there will be a time difference between them and the original medical records, and the paper color and bill freshness will be different. By comparing the traces of paper and ink with the state when the medical record was formed, we can basically make a preliminary judgment, and when in doubt, we can make it clear through document identification.
(three) to see whether the signature of the medical staff is true. In medical damage disputes, in many cases, the signatures of medical personnel are signed by others or medical personnel. At this point, we can find suspicious points by comparing the signature sequence of all military materials, and we can also identify them by handwriting identification.
(4) If the patient has copied some medical records before, the two medical records can be compared, and suspicious points can be found from the details such as signatures, record contents and typesetting of the two materials, so as to determine whether the medical records are forged or altered.
(5) It is worth noting that sometimes patients may not get a copy of their medical records until three months or even six months after their medical records are completed. Even if the original and the copy are the same at this time, it does not mean that the medical record has not been tampered with, but only that the copied medical record has not been tampered with.
Second, can medical records be tampered with for forensic identification?
According to the principle of who advocates and who gives evidence, if one party thinks that the medical record may be changed, the objecting party should apply for identification. After the court accepts the application for appraisal, it will organize both parties to select the appraisal institution and then conduct appraisal. Judging whether it can be used as evidence according to the appraisal conclusion.
Third, how to deal with forged medical records
It is illegal to forge medical records, and doctors and medical institutions who forge medical records should bear corresponding legal responsibilities.
Forensic medicine appraisal of medical faults can make an appraisal conclusion on the authenticity of medical records. According to Articles 13, 16 and 27 of the General Rules for Judicial Appraisal Procedures issued by the Ministry of Justice, the judicial appraisal institution does not accept the entrustment of untrue appraisal materials, and may terminate the appraisal if it finds that the appraisal materials are untrue during the appraisal process. Then the notice of rejection and the notice of termination of appraisal issued by the judicial appraisal institution or the forensic appraisal of medical faults, including the analysis and demonstration of the authenticity of medical records, medical faults and their causal relationship, will be a strong proof that medical records have been forged and can refute the technical appraisal of medical accidents made by the medical association.
According to Articles 2 and 25 of the Evidence Regulations, if a medical institution falsifies a medical record, which makes it impossible to identify the disputed facts of the case through the appraisal conclusion, and there is no evidence or the evidence is insufficient to prove its factual claim, it shall bear the consequences of losing the case because it cannot provide evidence. Therefore, once the medical records are found and proved to be forged by forensic identification, medical institutions will bear the consequences of losing the case.