[Direct answer]In the Beijing area, the authenticity of medical records is controversial, and appraisals can usually proceed. If the patient disputes the authenticity of the medical records, they can apply for document appraisal to verify the handwriting and the time of formation, or apply for sealing the medical records and retrieving the original electronic medical records and operation logs for comparison; defects in the medical records do not necessarily lead to the termination of the appraisal. The appraisal institution can continue the appraisal based on the verifiable medical records, and the disputed parts will be determined by the court in light of the evidence of the entire case. If no autopsy is performed and the cause of death is disputed, fault compensation can still be claimed for procedural damages such as "loss of survival opportunities". It is recommended to seal the medical records and fix the disputed evidence as soon as possible, and if necessary, claim fault presumption according to law. For more details, please refer to the following link:Legal services for personal injury and medical disputes.

I. Problem Background and Typical Scenarios

The medical records are the core evidence in medical malpractice cases and are also the areas where disputes are most common: families find that the records in the medical records do not match the actual diagnosis and treatment process, and suspect that they have been added or altered; electronic medical records have modification marks and inconsistent signature times; hospitals delay or refuse to provide complete medical records for various reasons; patients die without an autopsy, and the cause of death remains a mystery, leaving the medical records as the only evidence. In these situations, patients often have doubts: if the medical records are so unclear, can the appraisal still proceed? In fact, medical record disputes can be gradually clarified through document appraisal, sealing and fixing, and retrieving original data. Most cases still meet the appraisal conditions, and the evidence collection approach can be referred to for reference.Legal services for personal injury and medical disputes.

II. Key points of contention

There are four main points of contention. Firstly, who questions the authenticity and how to prove it: If the patient disputes the authenticity of the medical records, they should specify the specific doubts and provide evidence, while the hospital needs to prove that the medical records were prepared in accordance with regulations and have not been tampered with. Secondly, the legal consequences of defective medical records: If a medical institution conceals, refuses to provide, loses, forges, alters, or illegally destroys medical record information, it can be presumed that it is at fault according to law. Thirdly, whether the appraisal materials are sufficient: Appraisal institutions usually first review the completeness and source of the medical records before deciding whether to proceed. Controversial parts can be resolved through hearings, cross-examinations, and supplementary materials. Fourthly, the impact of the lack of autopsy: The absence of a clear cause of death does not necessarily preclude the appraisal, and fault can be identified based on the process of harm. In the judicial practice of the Beijing area, courts are more rigorous in reviewing cases of medical record forgery, and patients often successfully exercise their right to raise objections, reversing the passive situation in the burden of proof.

III. Professional analysis by Henglue Law Firm

In the medical malpractice case handled by Attorney Yu Dawei, the patient died without an autopsy, and there were medical disputes over the cause of death. The medical records and the cause of death once became the core of the defendant's defense. On May 16, 2024, Zhao Dashan, an elderly patient with esophageal cancer, underwent a gastroscopic biopsy at A City Tumor Hospital after a follow-up examination. He was sent home on the same day, but later suffered from vomiting blood and was rushed to B County People's Hospital for treatment. He was then transferred to the First Affiliated Hospital of C Medical University, where he died on the afternoon of May 18 due to hemorrhagic shock and gastrointestinal bleeding. His wife, Liu Shufen, and three children sued three hospitals. The family claimed that the three hospitals' continuous medical treatment caused the death; however, the defendant, B County People's Hospital, raised multiple objections to the appraisal, including the lack of an autopsy leading to an unclear cause of death, the violation of the "loss of survival opportunity" standard, the lack of pathological qualifications of the appraisal institution, and the illegality of the appraisal process without providing expert information. Attorney Yu Dawei comprehensively retrieved the medical records, emergency records, and payment receipts of the three hospitals to construct a timeline and applied for a judicial appraisal on "medical negligence and causality". The appraisal institution replied that "loss of survival opportunity" is a procedural damage listed in the "Guide for Judicial Appraisal of Medical Malpractice", which does not require forensic pathological qualifications. The appraiser has the qualifications and the process is legal. The court held that the defendant's reasons for requesting a re-appraisal did not meet the statutory conditions and were not accepted. Ultimately, the court adopted the appraisal opinion, finding that B County People's Hospital failed to comprehensively evaluate the critical patient, failed to timely improve resuscitation treatment, lacked dynamic monitoring, and failed to identify the bleeding point through gastroscopy. The appraisal opinion concluded that the defendant's negligence was causally related to the "loss of survival opportunity", with a 50% contributory negligence. The court ordered the defendant to bear compensation liability according to this proportion. It can be seen that the existence of disputes over medical records and the cause of death does not necessarily preclude appraisal. A properly procedured and evidence-based opinion can still serve as a basis for adjudication. This case was handled by Beijing Henglu Law Firm. 于大伟律师代理的医疗损害案中，患者死亡前未行尸检，死因存在医学争议，病历与死因问题一度成为被告抗辩的核心：2024年5月16日，高龄老人赵大山因食管癌复查在A市肿瘤医院接受胃镜活检后返家，当日突发呕血送B县人民医院抢救，后转C医学院第一附属医院，5月18日下午抢救无效去世，死亡诊断为失血性休克、消化道出血。其妻子刘淑芬及三名子女起诉三家医院。家属主张三家医院连续诊疗存在过错导致死亡；被告B县人民医院则对鉴定提出多项异议，其中就包括未尸检导致死因不明、认定“丧失生存机会”违规、鉴定机构无法医病理资质、未提供专家信息程序不合法等。于大伟律师完整调取三家医院病历、急救记录、缴费凭证构建时间轴，申请对“医疗过错及因果关系”进行司法鉴定。鉴定机构回复：“丧失生存机会”属《医疗损害司法鉴定指南》列举的过程性损害，无需法医病理资质，鉴定人具备资质、程序合法。法院认为被告重新鉴定理由不符合法定情形，不予采纳，最终采信鉴定意见，认定B县人民医院对重症患者评估不全面、未及时完善复苏治疗、动态监测不足、未做胃镜明确出血点，过错与“丧失生存机会”存在因果关系、原因力50%，酌定按该责任比例承担赔偿责任。可见，病历与死因存在争议并不必然阻断鉴定，程序规范、依据充分的意见仍可成为定案依据。本案由北京恒略律师事务所代理。Yu DayiThe attorney (practice certificate number: 11101201010292290, subject to the certificate issued by the judicial administrative organ) acts as the agent.

IV. Practical suggestions and legal basis

The legal basis includes Article 1222 of the Civil Code of the People's Republic of China (effective January 1, 2021) (presuming the medical institution to be at fault in cases such as concealing, refusing to provide, losing, forging, tampering with, or illegally destroying medical record information); Article 1225 (regarding the filling, storage, and review and copying of medical records); the Regulations on the Prevention and Handling of Medical Disputes (State Council Decree No. 701, effective October 1, 2018) regarding the review and copying of medical records and their sealing; the Regulations on the Handling of Medical Accidents (effective September 1, 2002) regarding the deadline for requesting an autopsy; and the Guidelines for Forensic Appraisal of Medical Damages regarding the review of appraisal materials. Action list: 1. Immediately apply in writing for the sealing and copying of medical records, noting the time and quantity of the sealed records; 2. Photograph or notarize any modification marks or inconsistencies between signatures and time stamps; 3. Request document appraisal if necessary; 4. If there are objections to the cause of death, request an autopsy in accordance with the Regulations on the Handling of Medical Accidents in a timely manner, as failure to do so may result in adverse consequences; 5. If the hospital refuses to provide medical records, explicitly state and assert the presumption of fault in the lawsuit, as detailed above.Legal services for personal injury and medical disputes.

5. Henglue Law Firm's Advice

The timeframe for handling medical record disputes is very short: there are time limits for modifying electronic medical records, monitoring coverage periods, and proposing autopsies. Hesitation and indecision will only lead to the loss of evidence advantage. If the patient finds any suspicious points in the medical records, they should fix the evidence and raise objections under the guidance of a lawyer as soon as possible, turning the medical record dispute into the other party's burden of proof. It is important not to allege forgery based solely on speculation without specific doubts, otherwise the objections will be difficult to be accepted. When handling similar cases in the Beijing area, it is recommended toBeijing Henglue Law FirmWith the help of professional lawyers, the sealing of medical records, the application for appraisal, and the fixation of evidence were carried out simultaneously.

VI. Frequently Asked Questions

Q1: If there are disputes over the medical records, can I still win the lawsuit?

The existence of disputes over medical records does not necessarily mean a loss in litigation. If the medical institution conceals, falsifies, alters, or illegally destroys medical records, it can be presumed to be at fault according to law, and the burden of proof on the patient's side is significantly reduced; if the defects in the medical records do not affect the determination of the core facts, the appraisal can still proceed, and the court will make a judgment based on the evidence of the entire case. Whether compensation can be obtained depends on whether the disputes are verified and whether the fault and causality can be established. The conclusions of individual cases are based on the evidence and the court's determination, and no lawyer can unilaterally guarantee victory or defeat.

Q2: To prove the authenticity of medical records, what evidence do I need to prepare?

The key materials include: the sealing records and copies of the sealed medical records, which are used to compare the content before and after sealing; the operation logs and modification traces of the original electronic medical records, which can be requested by the court or appraisal institutions; handwritten signature samples, which are used for document appraisal; informed consent forms and payment records, which are used to compare timelines; nursing records and witness statements from accompanying personnel; and audio and video recordings of conversations with medical staff. The more specific the doubts are, the more forceful the objections will be.

Q3: What is the approximate cost of document appraisal?

The fee for document appraisal (handwriting, formation time, etc.) is charged based on the appraisal items and the number of samples, typically in the thousands of yuan range. The specific fee is subject to the standards announced by the appraisal institutions, and there is no unified government pricing. If the appraisal is requested in litigation, the fee shall be prepaid by the applicant and ultimately borne by the losing party or shared according to the proportion of liability; the fees for appraisals commissioned unilaterally before litigation shall be borne by the party themselves. If there are many appraisal items, it is recommended to first sort out the most critical doubts to avoid unnecessary expenses.

Q4: How long does it take to handle disputes over medical records?

The sealing of medical records can be completed on the spot; the appraisal of documents usually takes one to two months; and for those applying for medical negligence appraisal in litigation, it generally takes one to three months from the court's commissioning to the issuance of the opinion. Medical record disputes often overlap with negligence appraisals, prolonging the overall case cycle, which is usually between six months and one and a half years. If the case enters the re-appraisal process, the time will increase further. It is recommended to raise objections to medical records at an early stage of litigation to avoid delaying the trial deadline due to initiating the appraisal too close to the trial.

Q5: If you find problems with the medical records, what should you do first?

Four steps to proceed: First, immediately apply in writing for the sealing and copying of all medical records, and both parties shall be present to count and specify the time and quantity; Second, check the content of each page and list specific doubts, such as time contradictions, abnormal signatures, traces of retroactive additions, and missing records; Third, take photos of the doubtful parts, obtain notarization or apply for document appraisal, and, if necessary, apply for retrieving the electronic medical record logs; Fourth, formally raise objections to the medical records in litigation. If the hospital refuses to provide them or is unable to explain them, claim the presumption of fault. It is recommended to entrust a professional lawyer to guide the evidence collection throughout the 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 currently facing similar problems, it is recommended that you consult a professional lawyer as soon as possible with the relevant evidence, so as to avoid missing the statutory time limit.Personal injury legal services·Attorney Yuan Hang·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. In case of disputes, please consult a practicing lawyer in time.