Doctor's medical record signature violation, patient died, hospital was presumed fault compensation 490,000

Author: Medical Law Collection

Brief Introduction

The patient, Ms.

The patient believes that the city hospital did not have the corresponding rescue capability and risk assessment to treat Ms.

Court hearing

The court of first instance found that the "Hospitalization Permit" included in the medical record of the municipal hospital was not issued by Wang Moumou, the receiving doctor in the emergency department of the day, but by the director of the ICU, Li Moumou, when he compiled the medical records and put it into the medical record.

The Municipal Health Commission is not objective and truthful because of the existence of medical records in the municipal hospitals

In the litigation, the court entrusted two forensic appraisal centers based on the application of the municipal hospital and refused to accept the request on the grounds that the entrusted appraisal request exceeded the technical conditions and capabilities of the institution

The court of first instance held that the city hospital had tampered with medical records, failed to actually use the medicine according to the content of the notification, failed to inform the patient and other faults when changing the medication, and in the process of using alteplase drug thrombolysis, there were also failures to comply with the "Alteplase" The conditions required by the “Instructions”, the doctor’s failure to specify the medications in accordance with the informed consent form, the failure to follow the operating specifications during the thrombolysis process, and the failure to perform the duty of care are the main causes of the death of the patient.

The city hospital appealed against the situation, and the court of second instance rejected the appeal and upheld the original judgment

A brief analysis of the law

The medical record management system refers to the management of the writing, quality control, preservation, and use of medical documents in order to accurately reflect the entire process of medical activities, realize the traceability of medical service behaviors, safeguard the legitimate rights and interests of both doctors and patients, and ensure medical quality and safety.

In medical damage liability dispute cases, according to the principle of “who claims the evidence”, the patient needs to submit to the court evidence that the medical institution or its medical staff is at fault, and that there is a causal relationship between the diagnosis and treatment behavior and the damage.

In medical disputes, medical records, as the most primitive medical documents, are the most direct and important documentary evidence for handling medical disputes

As a carrier that accurately reflects the entire process of medical activities, medical records are of great significance to safeguarding the legitimate rights and interests of both doctors and patients, ensuring medical quality and medical safety.

(This article is the original version of the Medical Law Society, adapted from real cases, and aliases are used to protect the privacy of the parties)