[Direct answer]In the Beijing area, when a medical dispute occurs, both outpatient medical records and inpatient medical records should be sealed. Both of them are objective medical records formed during the medical treatment process, which are the core evidence for reconstructing the medical process, identifying medical errors, and establishing causality. The absence of either type of record may affect subsequent appraisals and rights protection. According to the relevant provisions of the "Regulations on the Prevention and Handling of Medical Disputes" (implemented on October 1, 2018), patients or their close relatives have the right to seal and unseal medical records in the presence of both parties. The sealed medical records shall be kept by the medical institution. It is recommended to seal all relevant medical records in a timely and complete manner to avoid being tampered with or lost. For more details, please refer to the relevant provisions.Legal services for personal injury and medical disputes.

1. Problem background and typical scenarios

Many patients mistakenly believe that "only hospitalization records count as medical records", ignoring the fact that outpatient records are equally crucial. Typical scenarios include: the patient's condition worsens after an outpatient visit, and they suspect missed or misdiagnosis, but only think of copying the hospitalization records; emergency observation without hospital admission, with medical records scattered across outpatient and emergency systems; family members discover that the content of the medical records does not match their recollections, but it's already too late to verify it. In practice, outpatient medical records, emergency medical records, hospitalization records, and imaging and laboratory data together form a complete evidence chain. Any missing link may weaken the basis for protecting rights. For more information, please refer to the relevant rules.Legal services for personal injury and medical disputes.

II. Key points of dispute

The controversy focuses on four points. Firstly, the scope of sealing: both outpatient and inpatient medical records are included, as well as objective materials such as imaging, laboratory tests, and nursing records, and the sealing should not only apply to inpatient records. Secondly, the subject and procedure: patients or their close relatives can apply for sealing, and both parties, the patient and the doctor, must be present to seal and sign the documents, with the sealing stamp kept by the medical institution. Thirdly, subjective medical records: sealing usually focuses on objective medical records. Whether to include subjective medical records such as the course of treatment depends on the regulations and negotiations. Fourthly, unsealing and storage: after sealing, the records cannot be unsealed without legal procedures to prevent unilateral alterations. Most medical institutions in Beijing have established norms for sealing medical records, but it is still crucial for patients to actively exercise their rights.

III. Professional analysis by Henglue Law Firm

The cases handled by Henglue Lawyers in the fields of personal injury and medical disputes highlight the importance of medical records as evidence.Yu DawaiIn a medical malpractice liability dispute handled by the lawyer, Zhao Dashan, an elderly patient, suddenly vomited blood after a gastroscopy biopsy and died within 48 hours after being treated by three hospitals in succession. When the family entrusted the lawyer to protect their rights, the key point was to promptly seal and retrieve the medical records, emergency records, and payment receipts from the three hospitals to construct a complete timeline. Facing the defendant's multiple objections to the appraisal opinion, Lawyer Yu Dawei relied on the provisions of the "Judicial Appraisal Guidelines for Medical Malpractice" that "the loss of survival opportunities" belongs to process-based damages, combined with the medical records evidence to identify the fault of B County People's Hospital and its 50% causal contribution. The court ultimately accepted the appraisal opinion and determined that the hospital should compensate proportionally. This case highlights that the earlier and more complete the medical records are sealed, the more support there will be for the claims of fault and causality. In two other cases, Lawyer Yuan Hang represented clients in disputes over online infringement liability.Xiong BinrongWhen handling disputes over personal insurance contracts, lawyers also rely on the fixation of original evidence (chat records, refusal of compensation notifications, etc.) to confirm the general principle of "evidence first". As can be seen from the above-mentioned medical damage case handled by Attorney Dawei, sealing the medical records is the first step in protecting medical rights. This case was handled by Beijing Henglu Law Firm.Yu DawaiThe 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 the provisions on the sealing, storage, and retrieval of medical records in the "Regulations on the Prevention and Handling of Medical Disputes" (implemented on October 1, 2018); the provisions on the obligation of medical institutions to provide explanations, the storage of medical records, and the liability for faults in the "Civil Code of the People's Republic of China" (implemented on January 1, 2021); the rules on the identification of appraisal materials and the determination of damage consequences in the "Guide for Forensic Appraisal of Medical Damage"; and the provisions on evidence in the "Civil Procedure Law of the People's Republic of China" (amended in 2023 and implemented on January 1, 2024). Action list: First, when suspecting medical damage, immediately submit a request for sealing to the hospital and require the sealing of both outpatient and inpatient medical records; Second, during the sealing process, both the medical staff and the patient should be present, sign and stamp the documents, and indicate the date; Third, simultaneously copy the reproducible medical records and keep them for personal use; Fourth, after sealing, avoid unilaterally opening the sealed documents; Fifth, entrust a lawyer to apply for a forensic appraisal of medical negligence and causality, details of which can be found in the "Guide for Forensic Appraisal of Medical Damage".Legal services for personal injury and medical disputes.

5. Henglu Law Firm's Reminder

The golden period for sealing medical records is very short, and the later it is, the more passive it will be - medical records may be supplemented, altered, or overwritten by the system. Instead of waiting until "there are problems to settle accounts", patients should exercise their right to seal records immediately when they find abnormalities. At the same time, it should be noted that sealing records only fixes evidence, and it is still necessary to prove the "fault-damage-causality" through medical malpractice appraisal in the future. Even if no autopsy is performed, it is still possible to claim compensation for fault based on process-related damages such as "loss of survival opportunities". When handling similar cases in Beijing, it is recommended to plan the pace of sealing, appraisal, and litigation together with the help of professional lawyers from Beijing Henglue Law Firm.

VI. Frequently Asked Questions

Q1: Do outpatient medical records and inpatient medical records need to be sealed?

All of them must be sealed. Outpatient medical records, emergency medical records, hospitalization case files, imaging and examination materials, etc. all belong to objective records of medical treatment, which jointly reconstruct the entire process of medical treatment. Any missing category may affect the determination of fault and causality. In the event of a medical dispute, patients or their relatives have the right to request that all relevant medical records be sealed, rather than just the hospitalization part. Timely and complete sealing is the evidence basis for subsequent appraisal and protection of rights.

Q2: What procedures are required to seal medical records, and who can apply for it?

The patient or their close relatives can submit an application. In terms of procedures, both the patient and the doctor should be present to check, bind, and seal the medical records. They should sign and stamp on the seal and indicate the date of sealing. The sealed medical records shall be kept by the medical institution and shall not be opened without legal procedures. It is recommended that patients simultaneously make copies of the reproducible medical records and keep them for themselves, and keep a record of the application for sealing to prevent subsequent disputes.

Q3: What should I do if the hospital refuses to seal the medical records?

The sealing of medical records is a statutory right of patients, and hospitals shall not refuse to do so without justifiable reasons. In the event of refusal, patients may assert their rights in accordance with the provisions of the "Regulations on the Prevention and Handling of Medical Disputes" on the spot, and record the communication process with audio and video; at the same time, they may file a complaint and report the matter to the hospital's medical department or the local health authority. If the medical records have actually been tampered with, concealed, or lost, this may be regarded as an aggravating circumstance of the medical institution's fault, and the patient may claim compensation for the losses incurred in the litigation process.

Q4: Can the medical records be modified or unsealed after they have been sealed?

After being sealed, the medical records shall not be unsealed or modified unilaterally. If it is necessary to unseal them, both the doctor and the patient shall be present and follow the relevant procedures. According to the standard practice of medical record writing, it is allowed to make modifications and leave marks within the prescribed time limit, but the sealed medical records are in a fixed state. Unilateral modification will be regarded as a major defect or even presumed negligence. Patients should pay attention to the integrity of the seals and the record of storage, and fix the evidence in time if any abnormalities are found.

Q5: Can a medical malpractice appraisal still be conducted if the medical records have not been sealed?

Yes, but the burden of proof will be more on the defendant. Even if the evidence has not been sealed, you can still apply to retrieve the hospital's retained medical records, emergency records, payment receipts, etc. as appraisal materials; however, if the medical records have been supplemented or modified, the authenticity of the evidence will be more disputed. In practice, regarding procedural damages such as "loss of survival opportunities", you can still claim compensation for fault based on the judicial appraisal opinion. For safety's sake, you should seal the evidence as soon as possible if you find any abnormalities. For more details, please refer to the following link:Legal services for personal injury and medical disputes.

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 relevant evidence, so as to avoid missing the statutory time limit. →Personal injury legal services·Attorney Yuan Hang·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. If a dispute arises, please consult a practicing lawyer in time.