Latest form of discharge note in Vietnam from 2023? What are the instructions on how to write discharge notes under the new regulations?
What is the latest form of discharge note in Vietnam from 2023?
The latest form of discharge note is issued in Appendix 3 enclosed with Circular 18/2022/TT-BYT of Vietnam.
Download the latest form of discharge note: Click here.
Latest form of discharge note in Vietnam from 2023? What are the instructions on how to write discharge notes under the new regulations? (Image from the Internet)
Instructions on how to write discharge notes according to the new regulations?
Based on the content of Appendix 3 enclosed with Circular 18/2022/TT-BYT of Vietnam, the way to write discharge notes is done as follows:
(1) Section of Social Insurance Number/Health Insurance Card
- Social insurance number: Enter the full social insurance number issued by the Social Insurance Agency (Only applicable when the social insurance agency officially announces the use of the social insurance number instead of the health insurance card number).
- Health insurance card number: ………….. Fill in the card code, including the alphanumeric part according to the information on the patient's health insurance card, in which the capital letters are (Only applicable until the social insurance agency has officially announced the use of the social insurance number instead of the health insurance card number).
(2) Diagnostic section
- Must describe in detail about health condition and write disease name or disease code. In case of a disease requiring long-term treatment, the recording of disease code and disease name shall comply with the provisions of Circular 46/2016/TT-BYT;
- In case of termination of pregnancy: Specify the reason for the termination of pregnancy (For example: stillbirth, pathological pregnancy, etc.).
- In case of nursing treatment: Specify the phrase "pregnancy care"
(3) Treatments section
Indications for treatment (In case of termination of pregnancy):
- Under 22 weeks of age, based on the actual condition to write the treatment method in one of the following cases: Miscarriage, abortion, abortion, cesarean section, except for the case of pregnancy reduction during the Vitro Fertilisation;
- From 22 weeks of age or older, clearly indicate whether it is a normal delivery, a surgical delivery or a caesarean section.
- Specify the gestational age (including the case of termination of ectopic pregnancy, the gestational age of the ovum needs to be clearly defined).
Determining the week of pregnancy is based on the date of the last menstrual period or ultrasound results in the first 3 months of pregnancy.
- Specify the time of termination of pregnancy: At ...hours...minutes … date .../month.../year...
(4) Notes section
Record the doctor's advice, How to record the doctor's advice in some cases:
- In case the patient needs to take leave for treatment or to stabilize his health after inpatient treatment:
+ Specify the number of days that the patient needs to take leave for outpatient treatment after being discharged from the hospital (from date, to date).
+ The decision on the number of days off must be based on the patient's health status but must not exceed 30 days, in case of termination of pregnancy from 13 weeks or more, not more than 50 days: tuberculosis under the national anti-tuberculosis program, the maximum rest period shall not exceed 180 days.
- In case female employees need to take maternity leave, after recording the number of days off, it must be clearly written as "for pregnancy care".
Example: Number of days off: 10 days to take care of pregnancy. The decision on the number of days off must be based on the patient's health condition but must not exceed 30 days.
- In case a pregnant woman from 22 weeks old or more has to terminate the pregnancy, it shall be recorded as premature birth or death of the child.
- In case of premature birth, specify the number of children and the child's condition after birth.
- In case the person has lost or has limited civil act capacity or the child is under 16 years old, the full name of the patient's father, mother or guardian must be written in full.
(5) Part of day, month, year and signature
- The date, month and year in the signature of the head of the treatment department must coincide with the hospital discharge date.
- In the section "Dean of Department": The Dean or Deputy Dean of the Department shall sign according to the working regulations of the health facility.
- In the section "Head of the unit": The head of the medical examination and treatment establishment or the person authorized by the head of the medical examination and treatment establishment may sign and seal the medical examination and treatment establishment.
In case the health facility has only one person competent to examine and sign the discharge note, that person only needs to sign and stamp the part of the head of the unit.
Can a lost discharge note be reissued?
Pursuant to Point a, Clause 5, Article 26 of Circular 56/2017/TT-BYT of Vietnam mentioning the re-issuance of discharge note as follows:
Responsibility of health facilities
…
5. Health facilities issuing discharge notes, birth certificate, confirmation of maternity leave, confirmation of poor postpartum health and confirmation of eligibility to receive social insurance benefits shall:
a) Re-issue the discharge notes, birth certificate, confirmation of maternity leave, confirmation of poor postpartum health and confirmation of eligibility to receive social insurance benefits in the following cases:
- It is lost or broken;
- The person signing the confirmations is ultra-vires;
- The seals appended on the confirmations are invalid;
- Information recorded on the discharge notes, birth certificate, confirmation of maternity leave, confirmation of poor postpartum health or confirmation of eligibility to receive social insurance benefits is incorrect.
In case of re-issuance, a “re-issuance’ seal shall be appended on the discharge notes, birth certificate, confirmation of maternity leave, confirmation of poor postpartum health and confirmation of eligibility to receive social insurance benefits.
Thus, according to the above regulations, when the hospital discharge certificate is lost, the health facility where the discharge certificate is issued is responsible for re-issuing the discharge note and appending a “re-issuance” seal on the discharge note.
Circular 18/2022/TT-BYT of Vietnam will take effect from February 15, 2023.
Thư Viện Pháp Luật
