[Direct answer]In the Beijing area, the medical institution may be presumed to be at fault and bear corresponding responsibilities. Article 1222 of the Civil Code of the People's Republic of China stipulates that if a patient suffers harm during the medical treatment process, and any of the following circumstances exist, it shall be presumed that the medical institution is at fault: (1) Violating laws, administrative regulations, rules, and other relevant medical treatment norms; (2) Concealing or refusing to provide medical records related to the dispute; (3) Losing, forging, tampering with, or illegally destroying medical records. In other words, if the medical institution forges, alters, or illegally destroys medical records, the law directly presumes that it is at fault, and the patient does not need to provide separate evidence of the fault. In addition, tampering with medical records may also face administrative penalties from the health administrative department, and in serious cases, it may involve criminal responsibility. Patients should apply for the sealing of medical records and fix evidence in a timely manner.

1. Problem background and typical scenarios

In medical disputes, medical records are the core evidence for determining the diagnosis and treatment process. Some medical institutions, in order to evade responsibility, retroactively write, modify, or even forge medical records after the fact. It is often difficult for patients to reconstruct the actual diagnosis and treatment process. At this time, the law provides protection for patients through fault presumption and evidence rules, and tampering with medical records may instead put hospitals at a disadvantageous position.

II. Key points of contention

First, the application scenarios of fault presumption. Second, the identification and evidence presentation of medical record tampering. Third, the procedures for sealing medical records and preserving evidence. Fourth, the boundaries between administrative and criminal liability. Fifth, the relationship between liability for compensation and appraisal conclusions.

III. Professional analysis by Henglue Lawyers

Henglue Lawyers explained this from two aspects: rules and operations. Firstly, presumption of fault: The law explicitly lists situations such as violating medical treatment norms, concealing or refusing to provide medical records, and losing, forging, or illegally destroying medical records. If any of these situations occur, it is presumed that the medical institution is at fault. Patients do not need to prove the medical institution's fault, and the medical institution must provide evidence to refute the presumption. Secondly, identification of tampering: To determine whether medical records have been tampered with, comprehensive evidence such as font and handwriting, paper and printing characteristics, electronic medical record system logs, consistency between nursing records and medical orders, and copies held by patients can be used. If necessary, verification can be obtained through appraisal or retrieval of electronic medical record backend data. Thirdly, evidence preservation: If patients discover that medical records may have been tampered with, they should immediately request copies and seal the records, file complaints with health administrative departments, or apply for court evidence preservation and investigation to prevent the evidence from being further altered. Fourthly, administrative and criminal liability: Forging or tampering with medical records violates medical management regulations, and the health administrative department may impose penalties such as warnings, fines, or suspension of practice. In serious cases, criminal liability such as forgery or destruction of evidence may apply. Fifthly, compensation linkage: Presumption of fault only addresses the issue of fault, while damages and causality still require verification through appraisal. The court will determine the compensation ratio based on this. Tampering with medical records by medical institutions may result in them bearing a higher liability ratio. In Beijing, the review of medical record authenticity is particularly strict when adjudicating medical disputes.

IV. Practical suggestions and legal basis

Action suggestions: First, copy and apply for the seal-up of medical records as soon as possible, and keep the copies in the patient's hands; Second, if any abnormalities are found, complain to the health administrative department in time and fix the evidence; Third, if necessary, apply to the court for evidence preservation and retrieval of electronic medical records; Fourth, cooperate with the appraisal to determine the damage and causality. For medical disputes, you can refer to the relevant provisions of the Medical Malpractice Liability Insurance Regulations.Personal injury and medical disputesFor matters involving evidence preservation and procedural relief, you may refer to the following documents for reference:Special servicesLegal basis: Articles 121 and 122 of the Civil Code of the People's Republic of China (both effective since January 1, 2021), the Regulations on the Prevention and Handling of Medical Disputes (effective since October 1, 2018) regarding the sealing and inspection of medical records, and the relevant provisions of the Medical Practitioners Law of the People's Republic of China. The specific application shall be subject to the currently effective laws, regulations, and judicial rulings.

5. Henglue Law Firm's Reminder

Firstly, altering medical records directly leads to the presumption of fault, making hospitals more passive. Secondly, sealing the medical records as soon as possible is a crucial step in protecting rights. Thirdly, the backend data of electronic medical records are important clues for verifying alterations. Fourthly, even after the presumption of fault, it is still necessary to conduct an appraisal to determine the losses and causalities. For cases involving medical disputes and medical record evidence, the parties concerned may proceed through the following channels:Personal injury and medical disputesThe service provides a comprehensive solution, which involves evidence preservation and the integration of various procedures.Special servicesFor plate-related issues, those involving administrative complaints can be referred to for reference.Land expropriation and demolition, and administrative litigationFor columns involving criminal responsibility (such as forging evidence), you can seek advice from usCriminal defense and criminal case filingTeam.

VI. Frequently Asked Questions

Q1: If the hospital alters the medical records, do patients still need to prove that the hospital made a mistake?

No, it's not necessary. According to the law, if medical records are forged, tampered with, or illegally destroyed, it is presumed that the medical institution is at fault, and patients do not need to prove the fault separately. The burden of proof lies with the medical institution to refute the presumption.

Q2: How did you find out that the medical records had been altered?

This can be determined by analyzing the handwriting, paper and printing characteristics, inconsistencies in the timing of nursing records and medical orders, electronic medical record system logs, and copies held by patients. If necessary, apply for an appraisal or retrieve back-end data for verification.

Q3: What should I do if I suspect the data has been tampered with?

Immediately request a copy of the medical records, apply for their sealing, file a complaint with the health administrative department, and, if necessary, apply for evidence preservation and investigation by the court. Acting as soon as possible can prevent the evidence from being further modified or lost.

Q4: Will there be administrative penalties for tampering with medical records?

Yes. If anyone violates medical management regulations, the health administrative department may impose penalties such as warnings, fines, and suspension of practice; in serious cases, criminal responsibility may be involved, and both medical institutions and relevant personnel may be held accountable.

Q5: Can I get compensation just based on the presumption of fault?

That's not enough. It is also necessary to prove the consequences of the damage and the causal relationship, which is usually determined by medical damage appraisal. The presumption of fault addresses the issue of fault, and the compensation ratio is determined by the court based on the appraisal and the circumstances of the case.

The above answer is based on the judicial practice in Beijing. The adjudication standards in other provinces and cities may vary. For specific cases, please refer to the local rules and evidence situation.

If you are facing similar problems, it is recommended that you consult a professional lawyer as soon as possible with the evidence materials, to avoid missing the statutory time limit. →Personal injury legal services·Beijing Henglu Law Firm

Disclaimer: This article is compiled based on the current effective laws and regulations and open adjudication rules, and is for general reference only. It does not constitute a formal legal opinion on specific cases. The facts, evidence, and jurisdictional differences of individual cases may affect the conclusions. If a dispute arises, please consult a practicing lawyer in time.