[Direct answer]The scope covers both subjective and objective medical records. According to Article 122 of the Civil Code of the People's Republic of China (effective January 1, 2021), patients have the right to access and copy hospitalization notes, medical orders, examination reports, surgical and anesthesia records, pathological materials, nursing records, and medical expenses, among other medical records. Article 10 of the Regulations on the Handling of Medical Accidents (effective September 1, 2002) stipulates that patients have the right to copy outpatient and inpatient medical records, medical imaging examination materials, and surgical consent forms. The "Regulations on the Management of Medical Records in Medical Institutions (2013 Edition)" further include subjective medical records such as discussion records of difficult cases, supervisors' ward rounds, consultation opinions, and discussion records of death cases in the scope of copying. To request a copy, applicants generally need to submit a written application and proof of identity, and the copies must be stamped with a certification mark by the hospital. Internal management records and unarchived records are not considered medical records and are not included in the scope of copying. For more details, please refer to the following link:Legal services for personal injury and medical disputes.

I. Problem Background and Typical Scenarios

When patients or their families want to protect their rights, the first step often gets stuck on the medical records: the hospital says they can only copy part of the materials, wait for the records to be archived, or get the department to sign off on them. After going through several rounds, they still can't get the complete materials. Some people don't know that copying and sealing are two different things. Copying is for daily reference, while sealing is for fixing disputes. In the practice of handling medical disputes in Beijing, medical records are the basic materials for medical malpractice appraisal, and whether the copy is complete directly affects subsequent rights protection. There are three things that need to be clarified: which materials have the right to be copied, which materials have boundaries, and what procedures to follow. For more information, please refer to the relevant rules.Beijing Henglu Law FirmPractical articles in the field of medical disputes.

II. Key points of contention

There are four main points of contention. Firstly, the scope of copying: objective medical records include outpatient and inpatient medical records, medical orders, examination reports, medical imaging data, surgical and anesthesia records, pathological data, nursing records, and discharge records, etc. Subjective medical records include records of difficult cases, rounds by senior physicians, consultation opinions, and records of death cases, which are also within the scope of copying according to the 2013 edition of the "Regulations on the Management of Medical Records in Medical Institutions". Secondly, restricted circumstances: internal hospital management records, unarchived records, and materials involving statutory confidentiality matters are generally not subject to copying. Thirdly, the boundaries of consultation opinions: consultation records that are recorded in the medical file and archived can be copied, but internal communication that is not archived is not included. Fourthly, the applicants and process: the patient himself or his authorized agent, and the legal heirs of the deceased patient can apply, and they need to submit corresponding proof materials.

III. Professional analysis by Henglue Law Firm

Obtaining complete and timely medical records is the first step in protecting rights in medical disputes. Attorney Yu Dawei once handled a medical liability dispute case: On May 16, 2024, an elderly patient named Zhao Dashan underwent a gastroscopy biopsy at A City Tumor Hospital for an esophageal cancer follow-up examination and returned home. However, he suddenly vomited blood that day and was rushed to B County People's Hospital for emergency treatment. Due to his critical condition, he was transferred to the First Affiliated Hospital of C Medical University, but died on the afternoon of May 18 after unsuccessful rescue efforts. The three hospitals provided continuous medical treatment for less than 48 hours, and the cause of death was diagnosed as hemorrhagic shock and gastrointestinal bleeding. After the family entrusted Attorney Yu Dawei to sue the three hospitals, the lawyer first obtained the complete medical records, emergency records, and payment receipts from the three hospitals to construct a timeline of medical treatment. He then applied for a judicial appraisal of medical negligence and causality, and ultimately identified B County People's Hospital as the responsible party. The defendant raised multiple objections to the appraisal, including the appraisal institution's lack of medical pathology qualifications, the unlawful determination of lost survival opportunities, failure to provide expert information, and unclear cause of death due to no autopsy. After the appraisal institution responded to each objection, the court accepted the appraisal opinion and determined 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 conduct gastroscopy to identify the bleeding point. The court also found a causal relationship between the negligence and the loss of survival opportunities, attributing 50% of the responsibility to the hospital and ordering it to bear compensation accordingly. This case shows that the completeness of medical record retrieval and fixation directly determines the direction of subsequent appraisal and litigation. The case was handled by Beijing Henglu Law Firm. 完整、及时地取得病历，是医疗纠纷维权的第一步。于大伟律师曾代理一起医疗损害责任纠纷案：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，因病情危重转C医学院第一附属医院，5月18日下午抢救无效去世，三家医院连续诊疗不足48小时，死亡诊断为失血性休克、消化道出血。家属委托于大伟律师起诉三家医院后，律师第一步即完整调取三家医院病历、急救记录与缴费凭证，构建诊疗时间轴；继而申请对医疗过错及因果关系进行司法鉴定；最终依鉴定结论锁定B县人民医院为追责主体。被告对鉴定提出多项异议，包括鉴定机构无法医病理资质、认定丧失生存机会违规、未提供专家信息、未尸检死因不明等。鉴定机构逐一回复后，法院采信鉴定意见，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。本案表明：病历调取与固定的完整性，直接决定后续鉴定与诉讼的走向。本案由北京恒略律师事务所代理。Yu DaweiAttorney (Practice Certificate No.: 11101201010292290, subject to the certificate issued by the judicial administrative organ) acting on behalf of the client.

IV. Practical suggestions and legal basis

The legal basis includes Article 122 of the Civil Code of the People's Republic of China (effective from January 1, 2021) (the scope of patients' rights to access and copy medical records); Article 10 of the Regulations on the Handling of Medical Accidents (effective from September 1, 2002) (the scope of patients' rights to copy medical records); the provisions on accessing, copying, and sealing medical records in the Regulations on the Prevention and Handling of Medical Disputes (State Council Decree No. 701, effective from October 1, 2018); and the Regulations on the Management of Medical Records in Medical Institutions (2013 Edition) (the scope of copying, the applicant's identity, and the application process). Action list: First, submit a written application for copying, attaching a copy of the applicant's ID card; if the application is made by an agent, an authorization letter must also be attached; if the patient has died, the legal heirs must apply with a death certificate and proof of kinship. Second, list the application materials, including outpatient and inpatient medical records, medical orders, laboratory reports, medical imaging data, surgical anesthesia records, pathology and nursing records, and consultation records. Third, verify whether the copies are stamped with a special stamp for medical record copying or a certificate seal. Fourth, if a dispute arises, apply for the sealing of medical records simultaneously to preserve evidence. Fifth, if the hospital refuses without a valid reason, file a complaint with the hospital's supervisory authority, as detailed in the regulations.Legal services for personal injury and medical disputes.

5. Henglue Law Firm's Reminder

The window period for copying medical records is very short: electronic medical records can be modified in the background, and paper records may be supplemented. Delaying the application may lead to changes in key content. Families should first copy and then seal the records, following a dual-track approach. If the hospital delays for reasons such as internal regulations or the need for departmental approval, they can file a complaint with the health administrative department. When handling similar cases in the Beijing area, it is recommended to do the following:Beijing Henglu Law FirmUnder the guidance of professional lawyers, a list of the required materials will be provided, ensuring that all relevant information is fully copied, thereby laying a solid foundation of evidence for appraisal and claims settlement.

VI. Frequently Asked Questions

Q1: If the hospital doesn't provide all the medical records for copying, can I still win the lawsuit to protect my rights?

Yes, but the difficulty will increase. According to Article 122 of the Civil Code and Article 10 of the Regulations on the Handling of Medical Accidents, patients have the right to access and copy relevant medical records. If the hospital refuses to provide the medical records without a legitimate reason, conceals them, or provides incomplete medical records, it may be held liable for negligence. If the patient obtains the medical records and applies for a medical negligence appraisal, and the appraisal determines negligence and a causal relationship with the damage, the likelihood of obtaining compensation is higher; if the medical records are missing and the facts cannot be clarified, the hospital may bear adverse consequences. The outcome of individual cases depends on the completeness of the medical records and the appraisal conclusion.

Q2: What materials do I need to bring when applying for a copy?

For patients who apply on their own behalf, they shall submit a written application and valid identity documents such as ID cards; for those who apply through authorized agents, they shall also attach a power of attorney and the agent's identity documents; for patients who have died, the application shall be submitted by their legal heirs, who need to provide a death certificate, a proof of kinship, and the heirs' identity documents. The application form shall specify the scope of materials, such as outpatient and inpatient medical records, medical orders, examination reports, medical imaging data, surgical and anesthesia records, pathological data, nursing records, and consultation records. The copies of the materials shall be checked to ensure that they are stamped with the hospital's special stamp for copying medical records or a certification seal.

Q3: Is there a charge for copying medical records, and how much does it cost?

Hospitals may charge a copying fee for medical records, the standard of which is determined by the provincial-level price and health authorities and varies across different regions. The fee is usually calculated based on the cost of paper and production per copy, typically ranging from a few cents to a few yuan per copy, subject to local regulations and hospital announcements. For medical imaging data, additional fees may be charged based on the storage medium. Generally, there is no copying fee for sealed medical records. If you have any objections to the charging items or standards, you can report them to the hospital's competent departments or the price supervision authorities.

Q4: The hospital is delaying the process. How long will it take to resolve this issue?

For those with complete procedures, the hospital should provide the copies promptly. In practice, it usually takes several working days to two weeks to complete the copying process; if the amount of data is large and needs to be archived and retrieved, it may take longer. If the hospital refuses or delays without a valid reason, the patient can file a complaint with the hospital's supervisory department, and the complaint will generally receive a response within a few weeks. After entering litigation, the patient can apply to the court to retrieve the medical records or order the hospital to submit them; the sealing of the medical records can be completed on the spot. Overall, in the case of smooth procedures, the patient can obtain the copies within the same month; in the case of disputes, it may take one to two months.

Q5: If I want to copy the medical records, what's the first step to do that?

There are four steps to proceed: First, submit a written application to the hospital's medical records room or designated department, attaching proof of identity and authorization materials, and listing the list of materials; Second, check the delivered copies item by item to confirm that they are stamped with the special stamp for medical record copying or a certification mark; Third, if there are disputes over diagnosis and treatment, apply for the sealing of medical records at the same time. The sealed records shall indicate the time and quantity, and both the doctor and the patient shall be present; Fourth, if the hospital refuses or delivers incomplete materials, file a complaint with the health administrative department, and if necessary, apply to the court for the retrieval of the materials in litigation. For complex materials, it is recommended to entrust a professional lawyer to assist.

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

If you are currently facing similar problems, it is recommended that you consult a professional lawyer as soon as possible with the necessary evidence materials, to avoid missing the statutory time limits.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. If you encounter disputes, please consult a practicing lawyer in time.