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the incident of a 6-year-old boy in cangnan, zhejiang, who was said to have died after receiving an iv drip has raised doubts again. according to a report by modern express on august 26, the boy had received an iv drip at the qianku town central hospital in cangnan county (hereinafter referred to as "qianku hospital") due to fever. he felt unwell after returning home and was sent to cangnan county third people's hospital (hereinafter referred to as "cangnan third hospital") where he died after failed rescue efforts. the boy's father, mr. su, questioned the hospital's "tampering with medical records." on september 25, a reporter from modern express (reporting email: [email protected]) learned from an interview that relevant staff of cangnan third hospital said that qianku hospital did modify medical records.

family members questioned why the medical records were modified

according to the medical records provided by mr. su to the modern express reporter, the first medical record was his son's visit to qianku health center, the time was 15:30 on august 20, and the diagnosis was "clear breath sounds in both lungs". after mr. su's son was declared dead at 22:28 on the same day, the second medical record issued by the hospital showed that the visit time was also around 22:28 on august 20, and the diagnosis content was changed to "coarse breath sounds in both lungs", and "accompanied by nausea and vomiting, and the vomitus was gastric contents once" was added.

mr. su told the reporter that around august 23, the staff of the cangnan county health and health bureau promised him that the medical records had never been modified. "until i showed them two different medical records, they never admitted that they had modified them." regarding the changes before and after the medical records, the cangnan county health and health bureau explained that the hospital where the patient was treated could supplement the medical records, and the supplementary part was "accompanied by nausea and vomiting, and the vomitus was once gastric contents." however, it did not explain the changes in "clear breath sounds in both lungs" and "coarse breath sounds in both lungs" in the two medical records.

latest developments: the hospital admitted to modifying medical records

on september 19, mr. su went to qianku health center again to negotiate related matters. "jin yixun, the party secretary of qianku health center, said that we have no right to view and seal the medical records." mr. su told the modern express reporter that it was not until he repeatedly reported to the higher authorities that the hospital's attitude changed.

at 4 p.m. on the 19th, a staff member of cangnan third hospital claimed that he was "invited by qianku health center and entrusted by the leadership of cangnan third hospital" to come to qianku health center to explain the situation. the staff member said that qianku health center did modify the medical records. however, since all medical records are electronic, the "original medical records" have been overwritten by the modified medical records, and qianku health center itself cannot see them.

the staff member then said that after the qianku police station and technical personnel intervened, the medical records before and after the modification had been retrieved and sealed by the police station. what mr. su received were the two medical records that were printed out by taking photos. "due to system limitations, the doctor's signature can be seen on the online medical records, but it cannot be seen when printed out," the staff member explained.

where did the “doctor” on the medical record go?

on september 20, the reporter called qianku health center about the incident. a staff member of the hospital first said that the original medical records had been handed over to the family of the deceased, but then changed his words and denied it, saying "i don't know the situation, don't ask me." in the afternoon of the same day, the reporter contacted the qianku police station, and the relevant personnel said that the case was still under investigation, but did not disclose the progress.

on september 23, staff from the qianku police station confirmed to mr. su that the two medical records that were "sealed" by the qianku health center and handed over to the police also did not have the doctor's signature and were consistent with the medical records in mr. su's hands.

on the afternoon of the 23rd, the medical administration section of the cangnan county health and family planning bureau responded to a reporter from modern express that the local hospital's electronic system was indeed developed by the bureau, but the doctor's signature on the electronic medical record was unclear. "if the printed medical record mr. su received did not have a doctor's signature, then it is possible that the online electronic medical record did not have a signature either."

"signature doctor" surfaces, reasons for modifying medical records unknown

on september 24, the medical administration and information departments of the cangnan county health and family planning bureau showed mr. su the electronic medical records from qianku health center. the page showed that the doctor named on the modified electronic medical record (the time was shown as 22:28 on august 20) was zhang, who is currently a doctor at qianku health center. the bureau staff also said that the system could not view modification traces and background records.

the revised electronic medical record with the doctor's signature displayed by the cangnan county health and family planning bureau

"the staff of cangnan county health supervision office told me that zhang moumou verbally admitted that she had modified the medical records, but did not explain the reason for the modification." mr. su told reporters that the cangnan county health supervision office had said that the results would take three months to be available. "the staff of cangnan third hospital once said that if a doctor's signature was required, zhang moumou could sign it. but i never met this doctor from beginning to end."

why did zhang change his medical records? on september 25, modern express reporters called the cangnan county health supervision office several times, but no one answered. previously, the cangnan county health and family planning bureau said that the results of the county health supervision office's investigation would be announced on the zhejiang government affairs website. as of press time, the zhejiang government affairs website has not yet released relevant explanations.

in fact, the country has made many regulations on electronic medical records. according to the "regulations on the prevention and handling of medical disputes" promulgated by the state council and the "notice on issuing the (trial) specifications for the application and management of electronic medical records" issued by the general office of the national health and family planning commission (now the national health commission) and the general office of the state administration of traditional chinese medicine, no unit or individual may tamper with, forge, conceal, destroy or rob medical records; the electronic medical record system should identify the operator and save the traces of all operations to ensure that the operation time and operator information can be queried and traced.