Article 1225
Medical establishments and their medical personnel shall, in accordance with regulations, fill out and properly keep medical records such as hospitalization records, doctor's orders, test reports, surgical and anesthesia records, pathological data, and nursing records.
Where patients request to review or reproduce the medical records provided for in the preceding paragraph, the medical establishments shall promptly provide them.
1. The main purpose of this article
This article is about the obligation of medical institutions to keep medical records and the right of patients to consult and reproduce medical records.
II. Evolution of the Provisions
Article 61 of the original Tort Liability Law stipulates that: "Medical institutions and their medical personnel shall, in accordance with regulations, fill in and properly keep medical records such as hospitalization records, doctor's orders, test reports, surgical and anesthesia records, pathological data, nursing records, and medical expenses." Where patients request access to or reproduction of the medical records provided for in the preceding paragraph, the medical establishments shall provide them. This article basically retains the content of Article 61 of the original Tort Liability Law. In contrast, there are two main modifications: one is to modify "medical institutions should provide" to "medical institutions should provide in a timely manner". This is mainly due to the fact that in practice, some medical institutions delay the provision of medical records to patients under various pretexts. The legislature believes that it is necessary to emphasize the time limit for the obligation of medical institutions to provide medical record information, but the appropriate time to stipulate it should also take into account the number of medical record materials, the time of formation, the medical condition, etc., as well as the relevant diagnosis and treatment norms and differences in the practices of different medical institutions. The second is to delete "medical expenses". This is mainly because Article 19 of the Regulations on the Management of Medical Records of Medical Institutions (2013 Edition) removes "medical expenses" from medical records.
3. Interpretation of Provisions
This article is about the production, storage, and review of medical records.
Medical records are archival materials including hospitalization records, doctor's orders, test reports, surgical and anesthesia records, pathological data, nursing records and other medical data, which are usually divided into subjective medical records and objective medical records. No matter what kind of medical record data, it is a documentary evidence material in the liability for medical damages, and the real medical file is left by recording the process of diagnosis and treatment of patients by medical institutions.
The medical records are filled in and kept by the medical institutions, and the contents of the records are the patient's condition and diagnosis and treatment records. The medical records are under the control of the medical institution, and from the perspective of things, it is not an exaggeration to say that the medical institution has ownership of it.
Patients have important rights to medical records in the hands of medical institutions, as their health and life are at stake. Where patients request access to or reproduction of medical records, the medical establishments shall promptly provide them. This is the patient's right of access and reproduction of medical records. Medical establishments shall not only promptly provide access or reproduction, but must not pass the buck or refuse.
This article does not stipulate the liability of medical institutions in the event of a breach of their obligation to provide access or copying. For example, if a medical institution refuses or shirks a patient's request for access or copying, or even loses, destroys, forges or falsifies medical records, does the patient have the right to sue the medical institution for corresponding compensation? In this regard, the request for access or reproduction can be attributed to the scope of the patient's right to know, and the violation of the above obligations constitutes an infringement of the patient's right to know, and the patient may determine the medical institution's liability for moral damages in accordance with the general provisions on liability for medical damages provided for in Article 1218 of the Civil Code.
4. Cases
Chen et al. v. a county ethnic hospital, a dispute over liability for medical damages
Facts: In 2016, Chen Mouzhen was hospitalized in the acupuncture department of the county hospital for ethnic groups, and developed dangerous symptoms during the infusion process, and the hospital gave active rescue and recommended that he be transferred to a higher-level hospital. The patient suddenly stopped breathing and cardiac beating after getting into the ambulance, and died during the rescue process. The patient's close relatives, Chen, and others sued the County Nationalities Hospital and the County People's Hospital for compensation for losses. The court of first instance held that the negligence of the county ethnic hospital was mainly manifested in the lack of records of the course of illness and the irregularity of the rescue records, and determined that it should bear 20% of the liability. The county people's hospital has taken active rescue measures and is not liable for compensation in this case in accordance with the law. The county ethnic hospital was dissatisfied with the first-instance judgment and appealed. The court of second instance held that the county hospital for nationalities did not take corresponding diagnosis and treatment measures for Chen Mouzhen's early symptoms, which delayed the best time for treatment, so there was a certain fault in the diagnosis and treatment of Chen Mouzhen. Combined with the lack of "rescue records" in the medical records written by the hospital, and the detailed records in the "nursing records" were not recorded as required, there was obvious medical negligence. The first-instance comprehensive determination that the county ethnic hospital should bear 20% of the responsibility was not improper, and this court affirmed it.
5. Analysis
This case involves the obligation of medical institutions and their medical staff to fill out and properly keep medical records in accordance with regulations. Article 61 of the Tort Liability Law specifically stipulates the production, storage, access and reproduction of medical records. Article 1225 of the Civil Code, on the basis of Article 61 of the Tort Liability Law, places special emphasis on "timeliness". In other words, in the diagnosis and treatment activities, medical institutions and their medical personnel should fulfill a high duty of care, fill in the medical records in a timely manner, and need to keep them properly afterwards, and provide them to patients in a timely manner for reference and copying. This obligation is mandatory. If this obligation is violated, the medical institution and its medical staff shall be found to be at fault. Where other constituent elements are met at the same time, it shall be found that the medical establishment bears liability for compensation. In this case, the county ethnic hospital failed to fill in the rescue records and nursing records in accordance with the requirements of the specifications for writing medical records, ignoring the objectivity, authenticity and timeliness of the medical records, and violating its statutory obligations, so it should bear the corresponding liability for compensation.