As a pivotal component of the governance system for medical damage liability disputes, the institution-building of medical damage identification exerts a far-reaching influence on the high-efficiency governance of this domain. How to achieve the adaptive construction of the medical damage identification system has long remained a central research focus in the field. Therefore, from the perspective of institutional change theory, this study systematically examines two developmental phases that medical damage appraisal has undergone since the new century: the dual-track operation phase and the dual-track integration phase. It conducts an in-depth analysis of the modalities of local governance and their practical predicaments under the phased institutional paradigms, and carries out theoretical interpretations and change management analyses on the institutional transition from dual-track operation to dual-track integration in this domain. The purpose is to provide an explanation for the institutional genesis of medical damage identification, thereby offering historical insights for subsequent institutional reforms and innovations in the field.