Diagnosis and treatment.
The plaintiff went to the defendant on February 20 of a certain year due to irregular menstruation, and the physician prescribed an ultrasound medical imaging examination and urine specimen examination for her, and informed the plaintiff that she was pregnant according to the results of the examination, but she had had a spontaneous abortion, and the embryos and other tissues in the uterus were not completely discharged, and further uterine evacuation surgery was required. At 15 o'clock on the same day, the plaintiff went to the defendant to undergo uterine evacuation surgery and went home to recuperate. After that, the plaintiff ** was still bleeding and accompanied by abdominal pain, and 10 days later, he went to the defendant again, and was diagnosed with a ruptured pregnancy in the ampullary abdomen of the right fallopian tube.
Medical negligence. The doctor failed to fulfill its obligation to inform the plaintiff of the diagnosis and treatment
First, the materials provided by the entrusting party did not record the indications, purposes and possible complications of the patient's dilation and curettage, and the dilation and curettage did not sign the informed notice (the key contents of the surgical informed consent form submitted by the defendant in this case were completely altered and covered with a black pen, and the handwritten modified content was not confirmed by the patient's signature, so the court and the plaintiff did not recognize it and did not submit it to the appraisal agency as evidence).
Second, in response to the plaintiff's ultrasound, the defendant failed to inform and explain the results of the examinationThe doctor violated the diagnosis and treatment norms and routines, and only partially examined the patient's symptoms, and the examination measures were not comprehensive, and there was a lack of further examinations such as blood HCG, posterior fornix puncture, etc
Third, the doctor did not make a differential diagnosis and did not consider the possibility of ectopic pregnancy, so he performed uterine curettage according to the thickening of the endometrium, resulting in the missed diagnosis of ectopic pregnancy and delaying the plaintiffThe plaintiff had lower abdominal distension and pain with ** bleeding before the visit, and the rupture of the fallopian tube pregnancy was mainly caused by the inevitable outcome of the plaintiff's own condition.
In summary, the defendant was at fault for the plaintiff's diagnosis and treatment, and there was a certain causal relationship with the consequences of the damage, and the fault was a secondary cause.
The court reasoned].This court held that this case was a dispute over liability for medical damages. Article 1218 of the Civil Code of the People's Republic of China stipulates that if a patient suffers damage in the course of diagnosis and treatment, and the medical institution or its medical staff is at fault, the medical institution shall be liable for compensation. This court finds that the conclusion of the appraisal opinion is clear and the basis is sufficient.
With regard to the defendant's objection to the judicial appraisal opinion on medical damages, the key contents of the surgical informed consent form submitted by the defendant in this case were completely altered and covered with a black pen, and the handwritten modifications were not confirmed by the patient's signature. Moreover, the document did not contain any record of medical risks, alternative medical treatment options, etc., which was insufficient to prove that the defendant had fulfilled his obligation to explain and inform before performing the curettage.
In summary, this court adopted the appraisal opinion and found that the defendant should be liable for medical damage to the plaintiff, and the liability ratio was 30.
Verdict].1. The defendant shall compensate the plaintiff for the loss of 132637 within seven days from the date on which this judgment takes legal effect8 yuan;
2. The plaintiff's other litigation claims are rejected.
Case** on the judgment website, if there is any infringement, please contact to delete.
Personal opinion].#
How to modify medical records to be legal and reasonable?
The "Basic Standards for Medical Record Writing" stipulates that when there is a typo in the process of writing a medical record, it should be crossed out on the typo with a double line, and the original record should be kept clear and legible, and the modification time should be indicated and the person who revised it signed. Do not use scraping, sticking, painting, etc. to cover up or remove the original handwriting. In this case, because the modification of the surgical consent form did not conform to the norms, the court and the plaintiff did not recognize it after it was submitted as evidence, and was excluded from the appraisal materials, which was an important reason for the defendant's liability.
#
Why is there another situation of missing diagnosis and responsibility?
Missed diagnosis does not necessarily mean that you will be held responsible, but it is necessary to see whether the missed diagnosis is in line with the diagnosis and treatment behavior at the time and what kind of damage consequences it produces. If most medical personnel are likely to miss a diagnosis in the circumstances, the medical institution is not responsible in this case. The reason for the missed diagnosis in this case was not because the medical institution was not adequate, but because the sense of responsibility was insufficient, the plaintiff's diagnosis and treatment information was not understood in detail, the auxiliary examination report was not carefully analyzed, and the necessary examinations such as HCG were carried out, and the result was that one of the plaintiff's fallopian tubes was removed, constituting a grade 9 disability, and it is not surprising that the defendant was liable.