Brief description of the condition:At about 16:00 on November 18, 2020, the child went to Hospital A for taking antihypertensive drugs by mistake, and the child's grandfather signed the admission notice, and the doctor wrote that he refused to be hospitalized, and there was no signature of the attending physician. The consent form for lower gastric tube is signed by the child's grandfather, and the doctor fills in the refusal of gastric lavage, which is signed by the physician. The inpatient medical records recorded that the admission time was 17:00 on November 18, 2020, and the discharge time was 03:00 on November 19, 2020.
Court trial: In the first-instance lawsuit, three appraisal institutions returned the appraisal because the plaintiff did not recognize the authenticity of the medical records. In this case, the refusal to be admitted to the hospital was filled in in the admission notice at 16:10 on November 18, 2020, and the refusal to be gastric lavage was filled in by the medical staff in the consent form signed by the child's grandfather. The refusal to be hospitalized and gastric lavage was filled in the admission notice and the gastric tube consent form, not in the refusal of informed consent for hospitalization and the refusal of medical consent. There were obvious contradictions in the medical records provided by the defendant, and the plaintiff did not recognize the authenticity, resulting in the forensic appraisal agency entrusted by this court twice not accepting the appraisal entrustment and terminating the appraisal. Death diagnosed as drug poisoning, cardiogenic shock, arrhythmia, congenital heart disease? , and drug poisoning (misuse of antihypertensive drugs) can also cause cardiogenic shock.
In summary, it was decided that the defendant should bear full liability, totaling 725,67236 yuan. Hospital A appealed against the judgment, but the court of second instance rejected the appeal and upheld the original judgment.
Brief Analysis:The Basic Standards for Writing Medical Records stipulate that medical institutions and their medical personnel shall fill in and properly keep medical records such as inpatient records, doctor's orders, test reports, surgical records, pathological data, nursing records, and medical expenses in accordance with regulations. The writing of medical records shall be objective, truthful, accurate, timely, complete, and standardized. If there are obvious contradictions or errors in the content of the medical record materials and cannot give a reasonable explanation, the producer shall bear the corresponding adverse consequences; If there are only typos in the medical record or the formal defects that are not written in accordance with the standard format of the medical record, it does not affect the determination of the authenticity of the medical record materials, which shows that the medical record is the core evidence in the litigation of medical damage liability disputes.
In this case, Hospital A made two obvious mistakes, one was the refusal of the informed consent form for hospitalization and the refusal of medical consent, and the form of such an important form notice did not design a separate template, but was handwritten on the consent notice and not signed, which was very prone to suspicion of fraud, and once it could not produce evidence, it should bear the responsibility of losing the lawsuit; The second is the issue of signature, if the medical staff writes on behalf of the patient, the patient should be asked to put his fingerprint on the "name" and "refusal" of **, and there can also be a video recording when informed. The doctor should do a good job in template design and personnel training in this regard.
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