Page 74 medical record modified 30 times; man undergoes fracture surgery, tangled in a nerve injury mystery—pre-hospital injury or medical malpractice?

Ask AI · How do 30 medical record edits hinder medical liability determinations?

A fracture of the right radius and bone not only left Liu with a disability, but also dragged him into a long, drawn-out struggle for his rights.

Although the hospital was punished twice for issues including modifying medical records dozens of times, four years later, the question remains: was the injury caused before he was admitted, or was it a medical accident during surgery that led to damage to his right median nerve? The answer is still a mystery.

What the whole incident left him with was a right hand rated as Level Six disability, a steel plate permanently implanted, tens of thousands of yuan in insurance claims rejected, and the current situation that his medical records have been altered in multiple places, making it impossible to carry out the relevant liability assessments.

Man discovers months after surgery for a radius fracture that his right median nerve is damaged

This year, 49-year-old Mr. Liu is from Xuzhou, Jiangsu. His years-long ordeal traces back to a traffic accident.

“The traffic accident occurred on March 14, 2022. At the time, I had a right radius fracture, and my knees were injured too.” Mr. Liu said that the same day he was admitted to Xuzhou Mining Group General Hospital with plans to undergo surgical treatment for the fracture injury. Mr. Liu said that when he was admitted, the sensation in his hand was normal. “At that time, CT and DR imaging tests were done, and my right-hand condition was reported as only a fracture.” Mr. Liu said that in addition, based on the medical records materials such as the nurse’s assessment after admission, nothing indicated any nerve problem. On March 16, the hospital performed surgery for his fracture, and at that time it did not mention any diagnosis or treatment of nerve damage, nor surgery-related content. In the preoperative discussion, the chief physician even specifically emphasized protecting the median nerve during the operation to avoid unnecessary injury.

In the hospital’s examinations, only a fracture was reported

After the surgery, Mr. Liu noticed that the function and sensation of his right hand were deteriorating, but at the time he considered it normal. Mr. Liu also said he was admitted to the hospital a second time for rehabilitation treatment, but there was no obvious effect. “With no other choice, a few months later I went to another hospital for diagnosis and treatment.” Mr. Liu said that after diagnoses at multiple hospitals, it was confirmed that his right median nerve was damaged. The ultrasound reports from multiple hospitals that Mr. Liu provided directly showed abnormal reports regarding the size, shape, and morphology of the right median nerve and ulnar nerve, while the earliest imaging abnormality at Xuzhou Mining Group General Hospital’s arm imaging only reported a fracture.

Subsequent examinations at multiple hospitals showed nerve damage

But the developments that followed were even more unexpected.

“The party at fault in the traffic accident needed to go through insurance to compensate me. After the insurance company’s professional medical consultant reviewed my materials, they accused me and the hospital of jointly forging the medical records.” Mr. Liu said. The medical consultant said that if nerve damage had been identified at the time of admission, it was mandatory to have related examinations. But the medical records contained no examinations about nerve damage. More importantly, if nerve surgery were performed, the patient would need to sign. Even if nerve problems were discovered during the fracture surgery, the surgery would need to be paused to inform the patient or their family about the nerve issue and have them sign the relevant documents. But the medical records did not contain any of that, so the other side suggested that Mr. Liu file a complaint with the health administration department.

The health administration department determined that the hospital engaged in nonstandard diagnosis and treatment; the hospital involved was punished twice

Mr. Liu said that when he copied his medical records, they showed a diagnosis of median nerve damage, but at the beginning there was no corresponding treatment. In the surgery, there were no related items, and he was not asked to sign any consent form. He also found that there was a charge for the same type of bone graft implant in the billing, but it was not shown in the surgical record. Therefore, in March 2023, Mr. Liu reported this to the Xuzhou Municipal Health Commission (卫健委).

In June 2023, the Xuzhou Municipal Health Commission issued administrative penalties to the hospital involved and the doctor involved, Mr. Wang. The penalty decision clearly stated that it found the hospital and medical personnel had behavior including failing to fill out medical record materials according to regulations and using the same-type bone graft implant material without the patient signing an informed consent form. It also confirmed that the admission record contained a total of five modifications to the admission diagnosis, of which three exceeded 24 hours. The diagnosis was not corrected in accordance with the regulations, which did not meet relevant requirements of the “Basic Standards for Medical Record Writing.” The commission issued a warning and a fine of RMB 30,000 to Xuzhou Mining Group General Hospital, issued a “Health Supervision Opinion,” and required the hospital to strengthen management of clinical use of medical consumables, as well as required the relevant medical personnel to immediately correct their nonstandard behavior. For the doctor involved, Mr. Wang, it issued an administrative penalty of a warning and a fine of RMB 10,000.

June 2023: related administrative penalty documents

However, the matter did not end there. Mr. Liu said that he had been admitted a second time to Xuzhou Mining Group General Hospital in June 2022 for a repair surgery, but afterward he found that the surgeon and the signing doctor were not the same person. And when he submitted the medical record materials again for insurance claim compensation, the other side’s medical consultant raised even more issues regarding medical record modifications. As a result, Mr. Liu filed for reconsideration with the local judicial authorities. “During this process, many rounds of mediation were also carried out, but in the end it was not successful.” Mr. Liu said that after a long wait, the application for reconsideration was approved.

In July 2025, the Xuzhou Municipal Health Commission again issued an administrative penalty decision, determining that Xuzhou Mining Group General Hospital, after borrowing the complainant’s medical record materials from the medical record room on March 24, 2023, lost them, and that in the electronic medical record system it was impossible to query information such as the times of each modification and the operators. The commission held that this constituted behavior of failing to properly preserve medical record materials according to regulations. Therefore, it issued a warning and a fine of RMB 25,000 to the hospital; and although the doctor involved, Mr. Cao, had unlawful behavior, no administrative penalty was imposed due to the two-year deadline for pursuing responsibility. “Actually, although this penalty decision letter does not show it, this investigation also involved the medical record modifications during the first hospitalization. The health commission staff called me and told me they found that there had also been tampering, including the modification of the preoperative summary and preoperative discussion content.” Mr. Liu said.

July 2025: related administrative penalty documents

The health commission’s third determination: the medical record was modified 30 times; the involved party suspects the modifications were intended to add ‘pre-hospital nerve damage’ content

Regarding this penalty, Mr. Liu still said he was not satisfied. He filed for another reconsideration, and the Xuzhou Municipal Health Commission conducted another investigation. In January 2026, it issued a written statement regarding the medical record modifications. The statement said that an investigation found that in the hospital’s electronic medical record system background, there were a total of 30 modification records during the patient’s first hospitalization, and all modification records were located at the physician’s signature place. It also provided detailed descriptions of modifications to key medical record materials, including the surgical informed consent form, preoperative discussion records, admission records, and doctor-patient communication records. As for the content that was modified, due to issues with the hospital’s electronic medical record system, the traces of modifications could not be preserved, making it impossible to view the related content.

January 2026: related statement issued by the Xuzhou Municipal Health Commission

“I took out the medical records and checked them one by one. According to this statement by the health commission, my medical records are 74 pages in total and were modified 30 times; more than 40 pages of the medical records were modified.” Mr. Liu said. Therefore, he suspected that the hospital accidentally touched his median nerve during surgery and then modified the medical records. “It’s understandable that doctors modify medical records within a reasonable time. But large-scale modifications exceeding 24 hours should be tampering and falsification—there is a problem.”

Mr. Liu said that in multiple record forms signed by anesthesiologists, none recorded a diagnosis of median nerve damage or surgical content involving nerve repair. They only recorded the fracture diagnosis content and procedures such as open reduction and internal fixation with a steel plate for the radius fracture. “I consulted professionals. During the surgery, the anesthesiologist is present the whole time. If there had been a nerve damage issue from the beginning, it would definitely show in the anesthesia record forms.” Therefore, Mr. Liu believes the hospital’s tampering of the medical records was intended to add ‘pre-hospital nerve damage’ content, in order to evade liability for a medical accident.

The man’s right hand was assessed as Level Six disability; insurance claims, medical liability assessments, and others were all rejected due to medical record modifications

According to Mr. Liu, during the second reconsideration period, he raised an application for disability assessment. In January 2025, the Xuzhou Medical University Judicial Appraisal Institute issued a judicial appraisal document determining that the current condition of the right hand of the appraisee constitutes Level Six disability.

Judicial appraisal document

“My right hand has no strength now, and my ability to perceive is limited. I can’t work normally.” Mr. Liu said. And his right hand is already not in conditions for further surgery. “The steel plate inside can’t be removed—it has to be kept there for life.”

Mr. Liu said that the medical side’s modification of his medical records made it extremely difficult for him to defend his rights. “Originally, the insurance company for the party at fault in the traffic accident could have compensated me, but because of the medical record modification issue, they have refused to pay compensation all along.” Mr. Liu said. Previously, he and the hospital had jointly applied for a medical liability assessment in Nanjing, and Mr. Liu also went to Nanjing as required, but it was still not accepted due to the issue that the medical records were modified in large quantities. “I didn’t know what assessment I should do to protect my rights. Not long ago I also consulted about medical associations’ issues related to medical accident assessments. They said that because there are problems with the medical records, it also can’t be assessed.”

The hospital admits there were problems in the medical process, denies that the nerve was injured during surgery, and suggests determining responsibility through assessments and litigation

So what is the stance of the relevant parties? Recently, reporters from Huashang Bao Feng News contacted the Xuzhou Municipal Health Commission and the Xuzhou Municipal Health Supervision Institute one after another, and both sides refused to respond to the matter.

Yang, Director of the Medical Accident Department of Xuzhou Mining Group General Hospital, provided a response. “The medical record issues aren’t as serious as he imagines. How could there be no medical record modifications?” Director Yang clearly stated that the state also allows medical record modifications, and medical record modifications are legal, but falsifying and tampering are not allowed. Regarding the reporter’s question about whether medical record modifications should also be carried out within the prescribed statute of limitations, Director Yang did not make further comments.

Regarding the issue of right median nerve damage as Mr. Liu described, Director Yang clearly stated, “This was caused by the car accident.” Director Yang also admitted that there were problems in their diagnosis and treatment process, and they didn’t pay much attention to the description at the time. Director Yang said that at the time, the patient believed that the hospital’s surgery caused his nerve damage. In fact, this was a misunderstanding. They had explained to the patient that the surgical site did not overlap and would not touch the nerve, but they couldn’t persuade the patient.

Director Yang said that as Xuzhou Mining Group General Hospital is a Grade Three Class A hospital, it would assume whatever responsibilities it should assume. “At that time the hospital had already paid to do the assessment, but it’s that he was unwilling to do it.” Director Yang said that the patient also went to Nanjing and signed the documents, but then suddenly refused to do it. In addition, the patient had sued before, but later withdrew the lawsuit.

Director Yang stated that the hospital hopes that the involved party can determine responsibility through an assessment and resolve the matter through judicial channels. “The hospital won’t close its doors, and the doctors won’t run away. Whether it’s an assessment or litigation, we will cooperate to the fullest extent.”

In response to the hospital’s claims, Mr. Liu said it was not that he was unwilling to undergo assessment; rather, because there were problems with the medical records, it could not be assessed. Then, what outcomes could there be from a lawsuit based on medical accident assessment and liability assessment? “The withdrawal of the lawsuit was due to other reasons unrelated to the case.”

Huashang Bao Feng News reporter Yang Dehe Editor Li Jing

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