LCQ10: Procedures for healthcare personnel to compile and modify medical records
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Question:
It has been reported that several medical incidents involving the subsequent modification of medical records have previously occurred in public hospitals, sparking controversy (e.g. a medical incident at Queen Mary Hospital in 2020 where a girl was suspected to have gone into a vegetative state due to delayed blood transfusion, which involved doctors modifying the medical records after surgery, and the family considered that the relevant contents had a critical impact on understanding the incident's circumstances). There are views that under the existing mechanism, there is no effective procedure to ensure the necessity and legitimacy of modifying medical records, which lacks protection for both healthcare personnel and patients. In this connection, will the Government inform this Council:
(1) whether it knows, among the complaints received by the Hospital Authority (HA) in the past five years, the respective numbers of complaints involving the procedures for compiling medical records, the accuracy of the contents of records and the subsequent modification of the contents of medical records;
(2) whether it knows if HA has currently formulated relevant guidelines on the procedures and conditions for healthcare personnel to compile medical records and modify their contents; if HA has, of the details, and whether it has plans to improve such guidelines;
(3) whether it knows, with respect to modifications made by healthcare personnel to the contents of the complied medical records, if HA currently has a mechanism in place to verify the accuracy of the modified contents; if HA has, of the details; if not, the reasons for that and the difficulties involved;
(4) as there are views pointing out that in the past, a single doctor was responsible for recording medical procedures and confirming all surgical steps in some surgeries, which might affect the accuracy of the records, whether the Government knows if HA will consider amending the relevant procedures to require two or more healthcare personnel to be responsible for recording and confirming, so as to avoid unnecessary disputes; if HA will, of the details; if not, the reasons for that; and
(5) whether it knows if HA will consider introducing different tools to record surgical procedures (e.g. making audio or video recordings with patients' consent) to protect both healthcare personnel and patients and reduce disputes; if HA will, of the details; if not, the reasons for that?
Reply:
President,
Having consulted the Hospital Authority (HA), our consolidated reply to the question raised by the Hon Chan Hoi-yan is as follows:
Healthcare personnel must comply with the relevant guidelines issued by their respective professional bodies, such as the Code of Professional Conduct issued by the Medical Council of Hong Kong. Besides, for the compilation and amendment of the medical records, healthcare personnel should also follow the requirements set forth in the HA's Clinical Data Policy Manual and Manual of Good Practices in Medical Records Management.
When compiling medical records, healthcare personnel, including doctors, must always uphold their professional ethics and are responsible for maintaining systematic, true, adequate, clear, and contemporaneous medical records. Given that healthcare personnel must prioritise the patient's clinical condition during treatments like surgeries, detailed real-time documentation may not always be feasible. To ensure the accuracy of medical records, healthcare personnel may from time to time need to compile, amend or supplement medical records subsequently. The HA has also in place mechanism for subsequent amendment of medical records. In cases where relevant medical records should be amended or supplemented with details, the electronic medical record system will automatically log the time and specifics of all updates, while preserving the original records to ensure transparency and traceability of all amendments.
The HA recognises the importance of accurately documenting surgical procedures to uphold patient safety and ensure transparency in healthcare. Currently, medical records are primarily compiled by the attending doctor based on the actual situation, and should be in line with the HA's clinical data policies and pertinent specialty guidelines. Subsequently, responsible healthcare personnel would upload these records to the clinical management system following verification and provision of electronic signature.
In fact, the HA's practice of requiring the responsible healthcare personnel to compile and verify medical records is consistent with the standard practice in the medical sector (including professionals in the private sector). Comparing to the approach commonly adopted in the sector, the HA's current arrangements for managing medical records and recording subsequent amendments via the electronic clinical management system ensures a higher level of transparency and traceability.
The HA is also proactively enhancing healthcare quality by, inter alia, incorporating medical equipment with recording capabilities and upgrading the electronic medical record system to facilitate maintaining medical image records. In instances where it is practically necessary (e.g., for clinical, educational, or research purposes) and practicable, the HA may record surgical procedures for future reference upon obtaining patient consent. Such arrangements must adhere strictly to patient privacy policies and data protection regulations, while ensuring that the recorded materials are utilised solely for specified purposes.
Over the past five years, the number of complaints received by public hospitals concerning the issuance or content of medical records/reports/medical certificates is tabulated as follows:
| Year 2020-21 | Year 2021-22 | Year 2022-23 | Year 2023-24 | Year 2024-25 |
| 27 | 37 | 79 | 41 | 41 |
The HA does not maintain breakdown of complaints related to the medical record compilation procedures, the accuracy of record content, or subsequent amendments to medical records.
Ends/Wednesday, July 16, 2025
Issued at HKT 15:30
Issued at HKT 15:30
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