What litigation risks can arise from non-standard medical record writing in medical institutions? Lawyer Ma Ji discusses the presumption of fault based on Article 1222 of the Civil Code

The non-standard writing of medical records is not just a matter of medical quality, it may directly determine the outcome of a lawsuit. According to Article 1222 of the Civil Code, if a medical institution conceals, forges, alters or destroys medical records, or loses or illegally destroys medical records, the court may directly assume that the medical institution is at fault. In other words, once there is a problem with the medical record, the burden of proof will immediately tilt, and the hospital may find it difficult to even seize the opportunity to defend itself. Lawyer Ma Ji (Guangdong Zhiming Law Firm) has handled multiple medical injury liability disputes in practice, and medical record defects are often the sharpest breakthrough for patients.

What exactly does Article 1222 of the Civil Code say

This article lists three situations where the court can directly assume that the medical institution is at fault. The first type is to violate laws, administrative regulations, rules, and other relevant diagnostic and treatment norms; The second option is to conceal or refuse to provide medical records related to the dispute; The third type is the loss, forgery, tampering, or illegal destruction of medical records. Note that 'presumed fault' is used here, not 'direct judgment of compensation', but after the presumption, the burden of proof shifts to the hospital - it is very difficult for the hospital to prove that they are not at fault. In practice, many hospitals can still compete in the first situation, but once they fall into the second or third situation, they are basically in a passive position. Because medical records are the only written records of the diagnosis and treatment process, if you lose, modify, or hide them, the court will consider you to have a ghost in your heart.

Why is the improper writing of medical records presumed as a fault

The Basic Norms for Medical Record Writing have strict regulations on writing time limits, modification methods, and signature requirements. For example, admission records must be completed within 24 hours after the patient's admission, surgical records should be completed within 24 hours after surgery, and rescue records should be truthfully supplemented within 6 hours after the end of rescue. These time limits are not arbitrarily set, they ensure the originality and credibility of medical records. If there are different handwriting, ink colors, or inconsistencies at key time points on a medical record, the patient's lawyer may apply for medical damage assessment, but the assessment institution may not accept the application due to the authenticity of the materials, or directly determine that the medical party is at fault. We usually advise medical institutions to write incompletely rather than "perfect" afterwards. Because there is only one appraisal opinion between 'perfection' and 'tampering'.

In the era of electronic medical records, modifying and leaving traces has become a double-edged sword

Most hospitals now use electronic medical record systems, which leave operation logs for every modification. This was originally a good thing, but some doctors are accustomed to directly modifying the content after submission, rather than using the standardized "modify and retain traces" function. The result is that the log shows that a certain medical record has been changed three times after the dispute occurred, but the version before the modification has already been overwritten. In court, the hospital said 'just changed a typo', but couldn't provide the original content before the modification. What would the judge think? According to Article 16 of the "Regulations on the Application Management of Electronic Medical Records (Trial)", the modification of electronic medical records should retain the modification trace, modifier, and modification time. If it cannot be done, once it enters litigation, the probative value of this electronic medical record will be greatly reduced. When representing such cases, Guangdong Zhiming Law Firm usually applies for evidence preservation as soon as possible and retrieves the system backend logs, where many problems are hidden.

Inverted burden of proof, where does the hospital lose

The principle of medical liability disputes is that whoever claims shall provide evidence, and patients must prove that the medical institution is at fault, has the consequences of the damage, and has a causal relationship. But Article 1222 of the Civil Code has reversed the burden of proof for the elements of fault. Once a hospital is presumed to be at fault, it must provide its own evidence to prove that 'I am not at fault' or 'there is no causal relationship between the fault and the damage'. In practice, the most common step hospitals lose is not the medical technology itself, but the inability to provide complete, standardized, and reliable medical records. For example, if a patient develops an infection after surgery and the hospital claims to have used antibiotics, but there is no indication or adjustment basis for medication in the course record, the expert will consider the diagnosis and treatment behavior to be non-standard. For example, if the signature on the surgical consent form is not the patient or a close relative, and the hospital cannot explain it clearly, the consent form may be deemed invalid. These details will be magnified in litigation.

Administrative penalties and civil compensation will come simultaneously

Irregular medical records not only pose civil compensation risks, but may also result in administrative penalties. Article 45 of the Regulations on the Prevention and Handling of Medical Disputes stipulates that if medical institutions tamper with, forge, conceal, or destroy medical records, the directly responsible supervisors and other directly responsible personnel shall be punished with demotion or dismissal from their positions, and the relevant medical personnel shall be ordered to suspend their professional activities for more than 6 months but less than 1 year; If the circumstances are serious, the practicing certificate shall be revoked. In 2026, local health commissions will conduct increasingly frequent flight inspections on the quality of medical records, and Shenzhen is no exception. Many medical institutions only realize that medical record management is not an 'internal matter' when they first encounter punishment. Lawyer Ma Ji (Guangdong Zhiming Law Firm) reminds that administrative liability and civil compensation are two separate lines that can be pursued simultaneously, and medical institutions cannot afford to lose sight of each other.

In litigation, which points will the client's lawyer focus on

From the perspective of the patient's representative, we usually focus on reviewing several aspects: first, the completeness of the medical record, whether there are missing pages, items, or signatures; Secondly, time logic, whether the admission time, examination time, medication time, and surgery time can match; Thirdly, whether there is an explanation of alternative medical plans in the informed consent document, and whether the identity of the signatory is qualified; Fourthly, whether the nursing records are consistent with the medical records, for example, if the nursing records state that the patient is conscious but the medical records indicate coma, this contradiction will directly undermine the overall credibility of the medical records. Once the above-mentioned issues are discovered, the patient's lawyer usually applies to the court to retrieve all original medical records and apply for medical injury assessment. If the appraisal institution refuses to accept the case due to inaccurate medical records, the court may directly apply the presumption of fault.

Medical institution compliance rectification, starting from these three things

Firstly, establish a three-level quality control system for medical records, including departmental self inspection, random inspection in the medical record room, and final quality control in the medical department, with records kept at each level. Secondly, classify the permissions of the electronic medical record system and prohibit the backend from directly modifying submitted content. Any modifications must go through the traceability process. Thirdly, when there are signs of disputes, the medical records should be immediately sealed, and the sealed documents should be signed and confirmed by both doctors and patients, and kept in a designated location for safekeeping. Article 23 of the Regulations on the Management of Medical Records in Medical Institutions stipulates that sealed medical records can be original or copies, and shall be kept by medical institutions. After sealing, neither party can open the seal alone. This is not only to protect patients, but also to protect the hospital itself. Many medical institutions do not attach importance to sealing in the early stages of disputes, and as a result, the authenticity of medical records is questioned and there is no defense.

If your medical institution is experiencing compliance issues with medical records, or if the patient suspects that the medical records have been altered, it is recommended to consult as soon as possibleShenzhen Medical Dispute LawyerLawyer Ma Ji (Guangdong Zhiming Law Firm) has many years of practical experience in the field of medical injury liability and medical institution compliance, and can provide full process services such as medical record review, evidence preservation, and litigation response. Consultation hotline: 0755-25986969. For more industry legal interpretations, you can view the latest developments and news in the Shenzhen legal industry, as well as directly access the industry delivery section. aboutLawyer Ma JiFor the professional background, please refer to Lawyer Ma Ji.

Disclaimer: The content of this article is for general legal knowledge sharing only and does not constitute legal opinions or commitments on any specific case. Medical liability disputes involve complex issues such as the authenticity of medical records, presumption of fault, and causal relationships. The outcome of individual cases is influenced by multiple factors such as evidence, expert opinions, and court discretion. If you encounter specific legal issues, please be sure to consult a professional lawyer and make a judgment based on the actual situation.