Author: Medical Law Exchange
Reprint please indicate the source: Medical Law Hui WeChat public account
The patient, Mr. Zhou (84 years old), called 120 for first aid because of asthma. After the patient got to the ambulance, he was in a coma. The medical records recorded that the patient was admitted to the County Hospital of Traditional Chinese Medicine at 8:04 for treatment. Immediately after admission, oxygen inhalation, oral nifedipine 5 mg, intravenous push of 20 ml of 0.9% saline, 20 mg of furosemide, and 0.25 of pyridoxine were administered, and intravenous access was maintained. After being treated with relevant rescue measures, due to the aggravation of the condition, at 8:45, there was no breathing, heartbeat, blood pressure 0/0 mg, both pupils were dilated and fixed, the reflex disappeared, and the electrocardiogram was isoelectric. He died clinically (no autopsy).
Detailed records of the doctor’s expenses: the admission time is 8:00, the first prescription time is 8:15, and the drug is still prescribed at 8:52. The patient’s doctor, Hu Mou, is an assistant physician.
The family members of the patient had objections to the death of the patient. After mediation by the local health and family planning bureau, the two parties reached an agreement that the county hospital of traditional Chinese medicine was not at fault in the diagnosis, treatment and rescue. Considering the difficulties of the patient’s family, A hardship subsidy of RMB 20,000 will be given, and the patient shall not entangle the hospital with this matter in the future.
Afterwards, the family members of the patient believed that the doctor Hu did not have the qualification to practice medicine independently and practiced medicine illegally. The hospital failed to rescue in time and falsified medical records, resulting in the death of the patient. The lawsuit demanded that the county hospital of traditional Chinese medicine compensate for various losses totaling more than 240,000 yuan.
The patient did not recognize the hospital medical record and did not conduct a medical fault identification. The county hospital of traditional Chinese medicine believes that due to the emergency when the patient was admitted to the hospital, the hospital first used the medicine from the ambulance to treat the patient, and then went to make up the prescription, so the time for prescribing the medicine and the time for rescue could not match. Assistant doctors can practice medicine under the guidance of superior doctors, and there is no illegal practice of medicine.
The court of first instance held that, because the autopsy and medical fault identification were not carried out, it could not determine whether the hospital’s diagnosis and treatment behavior was at fault and whether there was a causal relationship between the patient’s death and the diagnosis and treatment behavior. The hospital has made a reasonable explanation for the difference between the medication time recorded in the medical records and the prescribing time in the fee details, and does not support the patient’s request that the county hospital of traditional Chinese medicine be fully liable for the death of the patient.
However, as an assistant physician, Mr. Hu did not have the signature and seal of the instructing physician in the long-term and temporary medical order records in the medical records, which violated the relevant laws and regulations. , it is presumed that the county hospital of traditional Chinese medicine bears 10% of the responsibility, and the county hospital of traditional Chinese medicine is judged to compensate the patient for various losses totaling more than 18,000 yuan.
The patient does not agree and files an appeal. The court of second instance dismissed the appeal and upheld the original judgment.
The state implements a physician practice registration system. After being registered, physicians can practice in medical and health institutions according to the registered practice location, practice category, and practice scope, and engage in corresponding medical and health services. In addition to the medical and health institutions in townships, ethnic townships, towns and villages, and county-level medical and health institutions in hard and remote areas, practicing assistant physicians should independently engage in general practice activities based on medical and health services and their own practical experience. Under the guidance of a licensed physician. In this case, the diagnosis and treatment doctor Hu, as an assistant physician, practiced independently, which obviously violated the law and was presumed to be at fault by the court.
The medical records are the records and summaries of the whole process of diagnosis and treatment of patients by hospital medical staff. They are the most important basis for determining the facts of the case and clarifying the responsibility. The impact of medical record problems on the responsibility of doctors can be divided into two categories: those with substantial impact and those with no substantial impact. Substantial impact means that the court determines that the doctor has concealed, tampered with, or forged medical records, etc., and affects the court’s determination of the proportion of medical damage liability; There is no causal relationship between the damages and the flaws in the medical records are not enough for the court to presume that the doctor is at fault, or after the doctor’s reasonable explanation, the court will not accept the medical record objection raised by the patient after the trial. In this case, after a reasonable explanation by the doctor, the court found that the doctor did not falsify medical records.
Medical institutions and their medical staff shall fill in and properly keep medical records in accordance with the regulations of the competent health department of the State Council. If the medical record cannot be filled out in time due to emergency rescue, the medical staff should make a supplementary record within 6 hours after the end of the rescue, and make a note. No unit or individual may tamper with, forge, conceal, destroy or snatch medical records. In this case, the patient was in an emergency when he was admitted to the hospital. The hospital first rescued the patient, and then filled out the medical records, which was in line with the law. Therefore, the doctor’s interpretation was recognized and supported by the court.
In addition, this case also involves the situation in which both the doctor and the patient signed a mediation agreement and agreed that “the patient shall not entangle the doctor with this matter”, but no longer entanglement ≠ no longer sue. “The people’s republic of ChinaThe Civil Code clearly stipulates that if there is a major misunderstanding, fraud by one party, fraud by a third party, coercion, and obvious unfairness, the other party has the right to request the people’s court or arbitration institution to revoke it. Therefore, even if a mediation agreement is signed, the parties can exercise the right of revocation in accordance with the law if they comply with the law. After the agreement is revoked, a lawsuit can still be filed to claim relevant rights and interests.
(This article was originally written by the Medical Law Institute, adapted from a real case, using a pseudonym to protect the privacy of the parties)