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May 24, 2012

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Patients, courts sick of sloppy medical records

LOCALS have long complained about the scribbled medical records written by doctors, but the problem gets serious when the writing serves as the most important evidence in a medical dispute or malpractice case.

Sloppily written medical records are one of the biggest obstacles in medical dispute judgments, and the city is lacking in writing standards and record-keeping management of medical records, local judges say.

"Scribbled and incomplete medical records have added difficulty for medical associations to make an appraisal," said Jin Minzhen, deputy president of the Huangpu District People's Court.

"Many cases dragged on and on because the patients and their families were dissatisfied with the appraisal result and applied for a review from a higher-grade organization."

"The progress is time-consuming and frustrating for both patients and hospitals," Jin said.

Patients complained that medical records contained incomplete or untrue information about their diseases. They also highly suspected hospital staff of tampering with medical records to avoid legal punishment.

Lu Yiguang, a lawyer with Shanghai Kangxin Law Firm, said a client of his found his medical records were increased from 43 pages to 80 pages after he filed a lawsuit.

"Some medical records provided by the hospitals were either forged or tampered with," Lu said.

Although some hospitals in Shanghai have gone to electronic systems, most doctors still keep their old habit.


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