[Direct answer]The medical records were altered. The first step of the patient's evidence collection is to fix the evidence: immediately request a copy of all medical records and apply for their sealing. According to Article 16 of the "Regulations on the Prevention and Handling of Medical Disputes" (implemented on October 1, 2018), patients have the right to consult and copy outpatient medical records, hospitalization notes, medical orders, laboratory reports, surgical records, nursing records, and other medical records; for the altered parts, they can apply for handwriting identification or document identification to prove the concentration of modification time and content contradictions. According to Article 1222 of the Civil Code of the People's Republic of China, if the medical institution forges, alters, or illegally destroys medical records, it shall be directly presumed to be at fault, and the patient does not need to provide separate evidence of the fault. If the consultation and complaint fail, the patient should sue as soon as possible. The court will retrieve the original medical records for identification and simultaneously advance the medical damage appraisal to determine the causality and liability ratio. For related matters, please consult the relevant departments.Legal services for personal injury and medical disputesTeam.

1. Problem background and typical scenarios

Medical records are the core evidence for determining whether there was any negligence in medical treatment in medical disputes, and they are also the first battlefield for both parties to present and defend evidence. In practice, typical scenarios of altering medical records include: patients developing serious complications after surgery, and the medical side subsequently making additions and modifications to the surgical records and medical progress notes to cover up delays in observation and treatment; discrepancies between the signing time and content of the informed consent records, with the medical side retroactively modifying them; conflicting timelines of resuscitation and monitoring records, with nursing records being completely replaced; and patients discovering uneven ink depth, abnormal binding marks, or conflicting content between different versions of the medical records when copying them. With the popularity of electronic medical records, more covert forms such as back-end modifications and emergency supplementary entries have emerged. Once medical records are identified as tampered, not only will the medical side's evidence system be undermined, but it may also trigger a presumption of negligence, directly affecting the determination of liability.

II. Key points of contention

  • The distinction between alterations and normal modifications: The medical record writing standards allow for supplementary recording, correction, and annotation according to procedures, and such changes are considered compliant. However, deleting or altering key content without basis or concealing medical treatment defects constitutes tampering. The distinction between the two in individual cases often becomes the focus of litigation disputes in courtrooms.
  • Evidence collection methods and the feasibility of appraisal: Patients usually only have copies in their hands, and handwriting appraisal and document formation time appraisal usually require the original documents; for the modification of electronic medical records, it is necessary to retrieve the backend operation logs, which are difficult for patients to obtain on their own. This can only be achieved through evidence collection during the process of sealing up, filing complaints, or litigation.
  • The application effect of the presumption of fault: According to Article 1222 of the Civil Code, after the medical party is presumed to be at fault, the causality and degree of participation still need to be determined through medical damage appraisal and other means. The presumption of fault does not necessarily mean that the medical party bears all the responsibility. The patient still bears the burden of proof for the damage itself.

III. Professional analysis by Henglue Lawyers

The experience of Henglue Law Firm in handling medical dispute cases shows that the pace of dealing with medical record issues directly determines the outcome of the case. The first step is to seize time: After discovering signs of alteration, apply for the sealing of medical records as soon as possible. The sealing should be carried out in the presence of both the patient and the doctor, and the sealed materials should be signed and confirmed to prevent subsequent alteration. At the same time, copy and retain both objective medical records and subjective medical records (such as ward rounds records, consultation opinions, and discussion records of difficult cases). The second step is to fix the points of conflict: Cross-check the medical records with examination reports, imaging materials, and expense lists, and compile a specific list of time line conflicts and content changes. This is the basis for applying for handwriting identification and document review. The third step is to use multiple procedures simultaneously: First, file a complaint with the health authority to retrieve the electronic medical record backend logs through administrative investigation; then apply to the court to retrieve the original documents and commission an appraisal during the litigation. It should be noted that once the claim of tampering is supported, the presumption of fault will be established, but the proportion of liability still depends on the causal relationship between the damage and the medical treatment. Usually, a medical damage appraisal is needed. After the case is won, if it involves the implementation of compensation, it can also be combined with other measures.Creditor-debtor relations and enforcement case servicesEvaluate the execution path.

IV. Practical suggestions and legal basis

At the legal basis level: Article 121 of the Civil Code of the People's Republic of China (effective January 1, 2021) stipulates that if a patient suffers harm during the medical treatment process and the medical institution or its medical staff are at fault, the medical institution shall bear the liability for compensation; Article 122 lists three circumstances of presumed fault, including violating the provisions of laws, regulations, and medical treatment norms, concealing or refusing to provide medical records related to the dispute, and losing, forging, or illegally destroying medical records; Article 188 stipulates that the statute of limitations for seeking protection of civil rights in the people's court is three years, calculated from the date when the right holder knows or should have known that their rights have been infringed and the date when the obligee becomes aware of the infringement. Article 16 of the Regulations on the Prevention and Handling of Medical Disputes specifies the scope of medical records that patients have the right to review and copy. At the practical advice level: During the medical treatment process, pay attention to keeping the outpatient and emergency medical record handbooks and the original examination reports; in case of disputes, first seal up the relevant materials and then negotiate; require the medical side to stamp the copies of medical records; apply for retrieving the operation logs of electronic medical records; and pay attention to the three-year statute of limitations for claiming rights, which starts from the date when the harm is discovered.

5. Henglue Law Firm's Advice

It's not terrible if medical records are tampered with, but what's really terrifying is missing the opportunity for sealing and appraisal. Please remember three actions: immediately apply for sealing if you find any abnormalities; make copies of all medical records and keep them with stamps; and organize the conflicting points into a list and submit them to professional lawyers for evaluation. Tampering with medical records is a major procedural flaw on the part of the medical side. If used properly, it can directly change the pattern of liability determination; but if used improperly, for example, making claims based solely on copies without completing the appraisal, it will only put oneself at a disadvantage. For cases involving complex appraisal arrangements or cross-field disputes, you can also seek further advice.Special services and other case-related servicesIf you are facing similar problems, it is recommended that you consult with relevant evidence materials as soon as possible. You can do this byBeijing Henglu Law FirmAfter making an appointment for an interview, the lawyer will formulate an overall plan for preservation, complaint, appraisal, and litigation.

Q1: If the medical records have been tampered with, can we directly infer that the hospital is at fault?

The degree of modification. According to Article 1222 of the Civil Code of the People's Republic of China, if a medical institution conceals or refuses to provide medical records related to a dispute, or loses, falsifies, alters, or illegally destroys medical records, the court may directly presume that it is at fault. The key lies in the determination of "alteration": making additions or corrections to medical records in accordance with the writing standards and signing them as required constitutes a compliant modification; modifying key clinical content or covering up defects without a valid reason constitutes alteration. In litigation, the patient needs to first prove through appraisal or comparative analysis that the modification reaches the level of alteration. Once it is determined to be true, the presumption of fault takes effect, and the medical institution needs to provide counter-evidence to refute it, reversing the burden of proof.

Q2: How to apply for the sealing of medical records? What should I pay attention to?

After a medical dispute occurs, the patient has the right to request the sealing of medical records. The sealing process should be conducted in the presence of both the patient and the medical staff. The medical records should be placed in a sealed bag, signed or stamped by both parties, with the sealing date noted. The medical staff shall keep the sealed records, and both parties may request to be present when the sealing is opened. There are three key points: First, the action should be prompt, preferably completed on the same day or the day after the objection is raised, to prevent further alterations; Second, the scope of sealing should be comprehensive, including outpatient and emergency medical records, hospitalization notes, medical orders, examination reports, surgical anesthesia records, nursing records, and imaging materials; Third, simultaneously make a copy of the sealed records and keep it with a stamped seal. The sealed and self-retained copies should corroborate each other, preserving the basic materials for subsequent appraisal.

Q3: Can the copied medical records be subject to handwriting analysis?

It is usually quite difficult. Handwriting identification and the identification of the time of document formation have high requirements for the evidence materials. Copies often lose many details such as ink layers and paper indentations. Forensic institutions often require the provision of original documents, and it is rare for them to issue clear appraisal opinions based solely on copies. The reasonable strategy for the patient is to first secure the original documents: After obtaining the original documents through means such as sealing, administrative investigations by health authorities, or applying to the court for retrieval during litigation, they can then apply for appraisal. For electronic medical records, it is possible to request the retrieval of modification logs, operation accounts, and time records from the system backend, and their evidentiary value is often more direct than that of paper-based comparisons. The appraisal fees are generally prepaid by the applicant, and the burden-sharing method is ultimately determined by the court based on the outcome of the case and the liability ratio.

Q4: What should I do if the hospital refuses to copy or seal the medical records?

According to Article 16 of the Regulations on the Prevention and Handling of Medical Disputes, patients have the right to access and copy their medical records, and medical institutions shall provide them. If there are no legitimate reasons for refusal, patients may file a complaint with the competent health department, and the administrative authority shall order the medical institution to make corrections and deal with the matter in accordance with the law. It should also be noted that concealing or refusing to provide medical records related to disputes is itself a presumption of fault as stipulated in Article 1222 of the Civil Code of the People's Republic of China. The cost that the medical institution will pay for this may far exceed the cost of cooperating in providing the records. During the litigation stage, patients can also apply to the court for an investigation order or request the court to directly retrieve the original medical records from the medical institution. It is recommended to keep written records of each communication, and if the medical institution delays verbally, the patient can fix the claim evidence by sending a written letter by mail.

Q5: Is there a time limit for claiming that the medical records have been tampered with?

Yes. According to Article 188 of the Civil Code of the People's Republic of China, the statute of limitations for litigation is three years, calculated from the date when the right holder knows or should have known that his rights have been infringed and the date when the obligee knows or should have known that his obligations have been breached. If the medical records are found to have been tampered with, this may itself constitute the point at which the right holder becomes aware of the infringement of his rights. At the same time, attention should be paid to the limitation of the maximum period of rights protection. If the rights have been infringed for more than 20 years, the court will generally not provide protection. In practice, it is more advantageous to assert rights as early as possible: there are time windows for sealing medical records, retrieving electronic logs, and preserving surveillance footage. The longer the delay, the higher the risk of evidence loss. It is recommended to seal the medical records as soon as possible after discovering signs of tampering and consult a lawyer, while simultaneously calculating the statute of limitations to avoid procedural delays affecting substantive rights.

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