The medical record writing is not standardized, and another third-class hospital has been punished!

How hard is it to write medical records in a standardized manner?

The author | Zhao Xiaohua

Source| Medical Community (ID: vistamed)

Got fined 3 times!

According to the administrative penalty of Credit China (Suqian, Jiangsu), on March 17, Nanjing Drum Tower Hospital Group Suqian Hospital Co., Ltd. (hereinafter referred to as Nanjing Drum Tower Hospital Group Suqian Hospital) was twice warned and fined a total of 38,000 yuan by the local health commission for failing to fill in medical records in accordance with regulations, and ordered to immediately correct its illegal behavior.

It is understood that in addition to the two "fines" received this time, the hospital was warned by the Suqian Municipal Health Commission in July 2021 for not filling in the medical records as required, and fined 18,000 yuan. So far, the hospital has been punished three times in a row for irregular writing of medical records.

According to the official website of the hospital, the hospital was founded in 1905 as a tertiary first-class general hospital, which has undergone many name changes before and after, and is an earlier prefectural and municipal public hospital in China, and in July 2021, it was officially renamed Assuqian Hospital of Nanjing Drum Tower Hospital Group. The hospital covers an area of about 63,000 square meters and has 2,000 open beds.

Medical records of many hospitals write "stepping on the red line"

Xu Yucai, former deputy director of the Health Bureau of Shanyang County, Shaanxi Province, believes that as a medical document with legal effect, medical records are an important basis for medical disputes and litigation, and can also become an umbrella for medical personnel when critical, so the standardized writing of medical records is particularly important.

However, recently, there are still many medical institutions that have gone forward to "step on the thunder", including many top three hospitals.

On March 8, the Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine was fined 50,000 yuan for violating the basic norms for writing medical records. It is reported that the hospital is the first batch of tertiary first-class Traditional Chinese medicine hospitals in the country, with 1800 approved beds and 12 national key specialties.

On February 25, according to the results of the administrative punishment disclosed by the Wenzhou Municipal Health Commission, the Second Affiliated Hospital of Wenzhou Medical University was also given a warning and fined 12,000 yuan by the local health commission for failing to fill in the medical records as required.

On January 26, Credit China showed that the Provincial Hospital Affiliated to Shandong First Medical University (Shandong Provincial Hospital), which is also a top three hospital, was punished with a warning and a fine of 100,000 yuan for failing to establish and improve the internal quality management and control system and failing to fill in medical records according to regulations. In June last year, the hospital was also fined 15,000 yuan for failing to seal and write medical records in accordance with regulations.

Looking back at 2021, there are not a few medical institutions that have been punished for irregular medical record writing.

From September to November 2021, in less than two months, the Third Hospital of Hebei Medical University received three "fines" in succession due to irregular medical record writing, with a fine of 60,000 yuan. The writing of medical records can not be lost at all, before, the Fourth People's Hospital of Datong City was warned and fined 20,000 yuan for writing "local anesthesia" for medical record data "local anesthesia", etc.

In Henan, a number of top three hospitals, including Zhengzhou Central Hospital and the Third Affiliated Hospital of Henan University of Traditional Chinese Medicine, have been punished for irregular writing of medical records, among which in the 2021 Zhengzhou Municipal Publicity of Health Penalties, Zhengzhou Central Hospital was warned and fined 30,000 yuan for not filling in medical record information as required.

In fact, whether it is a large hospital or a small hospital, if you do not write medical records well, the consequences are very serious. According to the "Health Supervision and Observation" of the Zhengzhou Municipal Health Supervision Bureau, a hospital in Sanmenxia City, Henan Province, was involved in a medical dispute due to irregular writing of medical records, and finally the hospital compensated more than 200,000 for the family of the patient due to problems such as signing the medical records and failing to fill in the medical records according to regulations, and was also fined 15,000 by the local health commission.

It is necessary to write well and manage it well

"Can writing medical records cure the disease?"

"To write a medical record is to engage in formalism."

In the eyes of some doctors, medical records are trivial, and spending time writing medical records is a waste of time. Many healthcare provider managers are also unaware of the importance of medical records.

In fact, Peking Union Medical College Hospital has "three treasures": professors, medical records, and libraries. It is precisely because of this "three treasures" that it has made its talents emerge and pass on the torch. Concordia medical records are rich, rigorous and detailed, and have always been praised by peers.

It is reported that medical records are an important basis for patient diagnosis and treatment, the first-hand clinical data of scientific research, and the face of doctors, which directly reflects the medical quality, academic level and management level of a hospital. To this end, the state has also issued a number of policies and regulations to strictly supervise the writing or storage of medical records of medical institutions.

As early as March 2010, the former Ministry of Health revised and implemented the "Basic Norms for Medical Record Writing", which made more detailed provisions on the basic norms of medical record writing.

In October 2018, the State Council promulgated and implemented the Regulations on the Prevention and Handling of Medical Disputes, which clearly stipulates the legal liability for irregular writing and management of medical records.

It is clear that in any of the following circumstances, medical institutions and their medical personnel have one of the following circumstances, "failing to fill in and keep medical record data in accordance with regulations, or failing to make up for rescue medical records in accordance with regulations; refusing to provide patients with services to consult and copy medical record data; failing to seal, keep, and unseal medical record data and on-site physical objects in accordance with regulations", etc., the competent health department of the people's government at or above the county level shall order corrections, give a warning, and impose a fine of between 10,000 and 50,000 yuan; Directly responsible supervisors and other directly responsible personnel are to be given or ordered to be given sanctions of demotion or dismissal, and relevant medical personnel may be ordered to suspend their professional activities for between 1 month and 6 months; where a crime is constituted, criminal responsibility shall be pursued in accordance with law.

The Civil Code of the People's Republic of China, which came into effect on January 1, 2021, also points out that if a patient is harmed in the diagnosis and treatment activities and some medical records are irregular, it can be presumed that the medical institution is at fault.

The Law of the People's Republic of China on Medical Doctors, which came into effect on March 1, 2022, stipulates that physicians who implement medical, preventive and health care measures, sign relevant medical certification documents, must personally diagnose and investigate, and fill in medical records and other medical documents in a timely manner in accordance with regulations, and must not conceal, forge, tamper with or destroy medical documents such as medical records and related materials without authorization.

In fact, if you do not fill in medical records or keep medical records, you will not only be punished by health administrative regulations, but also may be punished by the regulations on the supervision of medical insurance funds.

The Regulations on the Supervision and Administration of the Use of Medical Security Funds stipulate that medical documents such as medical records are not only the "vouchers" and "basis" for proving the authenticity of medical services, but also the "vouchers" and "bases" for medical insurance payment, and also the "vouchers" and "bases" for medical insurance supervision and inspection to determine whether medical services have "violations".

If there is a problem with the medical record data, it may be considered that the medical service is fraudulent, and it may bear the medical insurance refusal or even be identified as fraudulent insurance fraud, and bear legal responsibility.

Xu Yucai said that for medical institutions, medical records are important evidence to prove that they have not done wrong, so they must be both well written and managed. If there is a problem with the medical record data, it may be considered that the medical service is fraudulent, and it may bear the medical insurance refusal or even be identified as fraudulent insurance fraud, and bear legal responsibility. (This article is published by "Seeing the Medical Community", reprinted with permission, and the author and source are indicated at the beginning of the article.) ）

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