[Basic Facts of the Case].
On April 30, the patient was admitted to the ICU ward of XX Hospital for 4 hours due to unconsciousness**, and had a history of hypertension, coronary heart disease, and diabetes. The patient was admitted to the hospital in a superficial coma, and the preliminary diagnosis was: cerebral infarction, pulmonary infection, type 2 diabetes, pleural effusion, hypoproteinemia, coronary heart disease, atrial fibrillation, and hypertension grade 3.
Check troponin 042ng/ml，bnp 6240ng/l；Leukocytes 1170*109 l, neutrophil percentage 89%. Blood gases showed metabolic alkalosis. Chest x-ray showed double pneumonia and bilateral pleural effusion to be ruled out. ECG monitoring showed rapid atrial fibrillation with a heart rate of 130-170 beats. On May 9, tracheotomy was given, sputum suction, and sputum culture showed that Streptococcus viridans + Neisseria mucosa, Klebsiella pneumoniae.
At 19:00 on May 26, due to the lack of sputum suctioning for a long time, more viscous sputum in the tracheal cannula was blocked, and the heart rate dropped to 38-42 minutes. At 20:50, he was given a ventilator to assist breathing, and at 22:40, he died after rescue efforts.
[Lawyer Analysis].
The medical prescription for cerebral infarction is not standardized;Acute myocardial infarction has not been clearly diagnosed, and heart failure and acute myocardial infarction have not been standardized**;The doctor did not suctioning sputum in a timely and effective manner;Failure to actively and effectively control lung infections and misuse of antibiotics.
Electronic medical record identification
The plaintiff argued that the defendant's medical records had been forged or tampered with, and applied for an appraisal of the authenticity and originality of the computer's electronic data, and the appraisal opinion was that after comparing the electronic medical records, there were modifications, deletions, additions, etc., which violated the relevant provisions of the Basic Standards for Writing Medical Records.
Court decision
After the plaintiff and the defendant reached an agreement, the hospital compensated the plaintiff for medical expenses, death compensation (5 years), mental injury solatium and other losses in a lump sumMore than 2810,000 yuan(Non-Beijing standard).
Medical Lawyer Comments:
In this case, the plaintiff decided to initiate the identification of electronic medical records because there was conclusive evidence that could prove that the medical records were forged and tampered with, especially that the patients had successive records of the course of illness and death records within one month after discharge, and that there were modifications, deletions, additions, etc. Due to the high cost of electronic medical record identification, most of which are 60,000 yuan, the cost has increased according to the number of medical records identified, so as the plaintiff should choose carefully.
As to whether the medical records were forged or tampered with, the court found different opinions. However, most of the electronic medical records that are identified as only having the time of modification and not retaining the traces (contents) of the modification are often not found to be forged or tampered with by the courts. For example, in this case, the computer background retains traces of modification, and after comparing the text of the electronic medical record, there are indeed modifications, deletions, additions, etc., and the court will generally find that the medical record has been forged or tampered with.
At present, the network information system of the hospital has been gradually improved, and the requirements of the Health Commission for electronic medical records have been gradually improved, and the electronic medical record system has been graded and evaluated.