[Direct answer]In the Beijing area, if a medical record is tampered with by a hospital, patients can still protect their rights, but they need to adopt correct strategies for evidence collection and legal procedures. The first step is to seal the medical record: patients should submit a written application to the hospital as soon as possible after the dispute arises, requesting a copy of the medical record related to the dispute and applying for its sealing to prevent subsequent alterations. The "Regulations on the Prevention and Handling of Medical Disputes" (Decree No. 701 of the State Council, implemented on October 1, 2018) clearly stipulates that medical institutions and their medical staff shall write and manage medical records in accordance with laws and regulations, and medical institutions shall take measures to prevent medical records from being tampered with, forged, concealed, or destroyed. The second step is to fix the evidence of tampering: if tampering has been detected, patients should take photos of the original medical record to preserve evidence and record the specific location and content of the alterations. At the same time, they should corroborate the original records with other evidence, such as prescriptions, examination reports, nursing records, imaging materials, and expense lists. The third step is to initiate a complaint: patients should file a complaint with the administrative department of health and require an investigation into the irregularities in medical record management. The fourth step is to claim the consequences of evidence obstruction in litigation. According to relevant provisions of civil litigation, if the documentary evidence is under the control of the other party and is refused to be provided without a legitimate reason, the other party may be held liable for adverse consequences. If the medical institution refuses to provide the medical record without a legitimate reason or provides a tampered record, it may be presumed that the facts unfavorable to it are established.Personal injury and medical disputesThe services in this column can assist in initiating legal protection for rights holders.

1. Problem background and typical scenarios

Common situations include: key information in the medical record being modified; time records being altered to evade responsibility; obvious inconsistencies in the medical record; hospitals refusing to provide medical records on the grounds that the patient has already been discharged; and some records being missing or inconsistent with each other.Special services and other casesThe evidence organization explanations in the column can be used for reference. Such disputes often occur in situations where the treatment effect is unsatisfactory and both parties have differences over the treatment process. Therefore, it is more crucial to fix the evidence and preserve the process in a timely manner.

II. Key points of contention

First, the legal characterization of the act of altering medical records. Second, the initiation of the procedure for sealing medical records. Third, the corroborating role of other evidence. Fourth, the applicable conditions of evidence obstruction. Fifth, the connection between administrative liability and civil liability. Sixth, the reliability of appraisals in cases of doubtful medical records, and the connection between preliminary rights determination and supplementary appraisals. Seventh, the criteria for distinguishing between alterations and standard supplementary records, which is the basis for determining their nature.Business and contract disputes in enterprisesThe analysis of evidentiary rules in the column can be used for reference.

III. Professional analysis by Henglue Lawyers

Henglue Law Firm typically handles medical record disputes in four steps. The first step is emergency evidence collection: taking high-definition photos or scanning the original medical records, and recording close-up images of any altered sections, noting the page numbers and locations. At the same time, copying or photographing all relevant materials as much as possible to avoid disputes arising from selective evidence collection. The second step is applying for evidence preservation: submitting a written application to the hospital, requesting a copy of the medical records and preserving the disputed records, specifying the scope and time of preservation. If the hospital refuses, it should be required to provide a written response or explain the reasons, forming evidence to prove the refusal. The third step is building a corroboration system: arranging prescriptions, examination reports, imaging materials, nursing records, expense lists, and drug distribution records in chronological order to see if they can corroborate the records in the medical records. In practice, even if the medical records are altered, other objective records can often restore the true process. The fourth step is designing a procedural path: simultaneously filing a complaint with the health administrative department for investigation and initiating a medical damage appraisal. However, it should be noted that if there are major disputes over the authenticity of the medical records, the appraisal institution may require first determining ownership or even refusing to issue an opinion. Therefore, it is necessary to apply to the court for evidence preservation of the medical records or first making a determination on the authenticity of the medical records when necessary.Labor arbitration and work-related injury compensationThe program path descriptions in the column can be used as a reference for further study.

IV. Practical suggestions and legal basis

Action recommendations: 1. Immediately take photos of the original medical records and mark the areas that have been altered; 2. Submit a written request to copy and seal the medical records, and retain the receipt; 3. File a complaint with the administrative department of health and wellness; 4. Collect other evidence such as prescriptions, examination reports, and invoices; 5. Assess whether it is necessary to apply for evidence preservation; 6. Communicate with professional institutions regarding the conditions for expert appraisal. Legal basis: - The "Regulations on the Prevention and Handling of Medical Disputes" (Decree No. 701 of the State Council, implemented on October 1, 2018), which stipulates the requirements for medical record writing and management, and the procedures for handling medical disputes; - Article 121-121 of the "Civil Code of the People's Republic of China" (implemented on January 1, 2021); - Article 106 of the "Civil Procedure Law of the People's Republic of China" (amended and implemented on January 1, 2022), which stipulates the provisions on evidence and the submission of documentary evidence; - Specific applications shall be subject to the currently effective laws, regulations, and judicial rulings.

5. Henglu Law Firm's Advice

Firstly, the medical records are the core of such cases, and it is essential to fix and apply for their preservation as soon as possible. Secondly, the determination of alteration requires objective evidence, and it is difficult to support the claim solely based on suspicion. Thirdly, administrative complaints and civil litigation should proceed in parallel, as administrative investigations may yield strong evidence. Fourthly, it is risky to apply for appraisal of the medical records rashly when there are doubts about them, as the materials may be deemed unreliable and require supplementation or suspension. Fifthly, attention should be paid to the rule of obstruction of evidence, which requires proving that the documentary evidence is under the control of the other party and that the other party refuses to provide it without a legitimate reason. Sixthly, there are prerequisites for mediation in the handling of medical disputes, and attention should be paid to the procedural order.Creditor's rights and debts, and enforcementThe column can also provide explanations on how to proceed with the next step.

VI. Frequently Asked Questions

Q1: If the medical records have been altered, can I still sue the hospital?

It's possible to sue. The fact that the medical records have been altered does not affect the party's right to sue, but can instead serve as an important clue to assert the hospital's negligence. When suing, the party can request the court to review the authenticity of the medical records and argue that the hospital should bear the corresponding adverse consequences for providing inaccurate medical records without a valid reason. It should be noted that if the hospital disputes the authenticity of the medical records during the litigation, the court will usually require the party to first confirm the authenticity of the records, or make adverse presumptions about the relevant facts if the evidence is obviously questionable. Therefore, it is recommended to complete three tasks before suing: taking photos to obtain evidence, applying for the sealing of the records in writing, and filing an administrative complaint, in order to form a complete chain of evidence.

Q2: What should I do if the hospital refuses to provide me with a copy of my medical records?

Three measures can be taken. Firstly, submit a written application to the hospital, clearly requesting to copy all medical records, including outpatient and inpatient records, and keep the application and receipt as evidence; if the hospital refuses on the grounds that the patient has been discharged or that it does not comply with regulations, require it to provide a written response. Secondly, file a complaint with the health administrative department of the hospital's location. Medical institutions shall provide patients with copying services for medical records in accordance with the law, and refusing to do so constitutes a violation of regulations. Thirdly, in litigation, apply to the court to order the hospital to submit the medical records and claim that the hospital's refusal to submit them without a valid reason should bear the adverse consequences of obstructing the production of evidence.

Q3: How can we determine whether the alterations were made by the hospital itself?

It can be judged by objective evidence: The standard practice is to retain the original records by drawing a double line when making amendments, sign it, and indicate the time of amendment. In this case, the amendment is allowed and traceable. If it is covered by blackening, scratching, tearing and replacing pages, or the fonts before and after are obviously different without a signature and time, it belongs to an unauthorized alteration. In addition, it can be compared with other evidence: inconsistencies between the prescription and the medical record, contradictions between the time of the examination report and the time of the disease course record, and inconsistencies between the nursing record and the medical order, etc., may all indicate that the medical record has been altered. In practice, it is recommended to form a written comparison table of the results, which is more convincing than a simple claim.

Q4: Can a medical appraisal still be conducted if there are problems with the medical records?

Yes, but the difficulty will increase significantly. The appraisal agency will review the completeness and authenticity of the medical records. If the medical records contain alterations, missing pages, or inconsistencies, the appraisal agency may require the hospital to provide additional explanations or even refuse to accept them. In practice, it is more prudent to first confirm the authenticity of the medical records, such as applying to the court for evidence preservation of the medical records or confirming the content of the records through litigation before initiating the appraisal. In addition, you can explain to the appraisal agency the specific locations and doubts of the alterations, and request them to evaluate the reliability of the medical records in the appraisal opinion. This approach is still feasible in some cases.

Q5: Is it necessary to mediate medical disputes first?

It is usually necessary. The relevant regulations on handling medical disputes require that parties can apply for mediation through the People's Mediation Committee for Medical Disputes, or directly file a lawsuit with the people's court. However, in practice, many cases can be resolved faster at the mediation stage. It is recommended to apply for mediation first and submit complete claims and evidence; if mediation fails, the litigation process will proceed. It should be noted that once a mediation agreement is reached, it is usually binding. Before signing it, the terms should be carefully checked, especially the compensation amount, payment time, and follow-up treatment arrangements. When participating in mediation, attention should be paid to the management of the statute of limitations, so as not to delay the opportunity for subsequent rights protection due to mediation.Special services and other casesThe column can also provide an explanation of the program process.

This article is written based on the common judicial interpretations in the Beijing area. If the case occurs in other regions, it is recommended to consult local lawyers to verify the regional differences.

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 Henglue Law Firm

Disclaimer: This article is compiled based on the current effective laws and regulations and public 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. In case of disputes, please consult a practicing lawyer in time.