Vietnam: Under Circular 32/2023/TT-BYT, what is the latest Medical Records Summary Form (Form No. 52/BV2)?
Under Circular 32/2023/TT-BYT, what is the latest Medical Records Summary Form in Vietnam (Form No. 52/BV2)?
Under the provisions of the latest Form No. 52/BV2 under Circular 32/2023/TT-BYT, the latest Medical Records Summary Form is specified as follows:
Download the latest Medical Records Summary Form (Form No. 52/BV2): Here
Is it possible to create electronic medical records in Vietnam?
Under the provisions of Article 69 of the Law on Medical Examination and Treatment 2023, the regulations on medical records are as follows:
Medical record
1. Patients undergoing inpatient treatment, day treatment or outpatient treatment in medical establishments shall have their medical records created or updated.
Physical and electronic medical records shall be of the same legal value. Forms or templates of medical records and medical record summaries shall be made available for use by the Minister of Health.
2. Medical records shall be safekept and kept confidential in accordance with law; if the medical record is classified as a state secret, the regulatory provisions of law on protection of state secrets shall govern. Depositing or archiving of medical records shall be subject to the regulatory provisions regarding archives.
3. Access to medical records of patients in treatment shall be as follows:
a) Learners, students, trainees, researchers of research institutions, training institutions, medical practitioners, persons directly involved in the treatment of patients at medical establishments may read medical records, and may copy medical records only when obtaining the consent from the safekeeping medical establishments;
b) Practitioners from other medical establishments may read and copy them with the consent of the safekeeping medical establishments.
4. Access to medical records of patients completing treatment that are kept as archives shall be as follows:
a) Representatives of state management agencies in charge of health, investigative agencies, procuracies, courts, health inspectors, forensic organizations, forensic psychiatrists, and patients' lawyers shall be allowed to access and provide medical records to perform their tasks in accordance with relevant laws;
b) Learners, students, trainees, researchers of research institutions, training institutions, medical practitioners at medical establishments may borrow medical records to read on the spot, or may copy medical records for later use in their researches or the work relating to their professional expertise with the consent of the safekeeping medical establishments;
c) Representatives of social insurance agencies or state compensation settlement agencies may borrow medical records to read or take notes on the spot, or request copies of the given medical records to serve the purpose of performing their assigned tasks with the consent of the safekeeping medical establishments;
d) Patients or their representatives specified in point c and d of clause 2 of Article 8 herein shall be entitled to read, view, copy and take notes from their medical records, and be provided with medical record summaries upon written request;
dd) Patients’ representatives specified in point a and d of clause 2 of Article 8 herein shall be entitled to medical record summaries upon written request.
5. When using information included in medical records, those specified in clause 3 and 4 of this Article must treat such information completely confidential and only use them for the given purposes as registered with the medical establishments.
Thus, it is possible to create electronic medical records in Vietnam. Physical and electronic medical records shall be of the same legal value.
What are the principles of the provision of medical services in Vietnam?
Under the provisions of Article 3 of the Law on Medical Examination and Treatment 2023, the principles of provision of medical services in Vietnam are specified as follows:
- Respect, protect, and treat patients equally, and stop stigma or discrimination towards patients.
- Give priority to have access to medical services to patients in a state of emergency; children aged under 6 years; pregnant women; people with extremely severe disabilities; people with severe disabilities; people aged 75 years or older; people rendering meritorious services to the revolution, depending on the particular characteristics of each medical establishment.
- Respect, cooperate with and protect practitioners and other persons on duty at medical establishments.
- Promptly implement and comply with regulations on professional and technical expertise in healthcare.
- Comply with the code of professional ethics in the practice of medicine approved by the Minister of Health.
- Ensure equality and fairness among medical establishments.
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