What is the latest form of medical record summary in Vietnam? How to fill out a medical record summary?
What is the latest form of medical record summary in Vietnam?
The latest summary form of medical records is issued in Appendix 04 issued together with Circular 18/2022/TT-BYT.
The most recent form of medical record summary is available here.
What is the latest form of medical record summary in Vietnam? How to fill out a medical record summary? (Image from the Internet)
How to fill out a medical record summary in Vietnam?
Pursuant to the content in Appendix 04 issued together with Circular 18/2022/TT-BYT, the summary form of the medical record is recorded according to the following instructions:
- The summary recording of medical records must ensure consistency with the patient's medical records;
- 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 the notes section;
- In case the child dies after birth, write the date/month/year of birth of the child and the date/month/year of the child's death, the number of children who died in the section on the patient's discharge status;
- Part of Social insurance number / Health insurance card: Enter the number of social insurance book or social insurance number. The recording of the social insurance number is only applied when the official social insurance agency gives notice of the use of the social insurance number instead of the social insurance book number.
Which agency has the authority to issue medical record summary in Vietnam?
Article 17 of Circular 56/2017/TT-BYT stipulates the level of summary of medical records as follows:
Issuance of medical record summary
1. Authority to issue medical record summary: Licensed health facilities providing outpatient treatment.
2. The discharge note medical record summary template is provided in Annex 4 enclosed herewith.
3. If the patient stays at a commune-level Health station as specified in Point a Clause 4 Article 7 No. 41/2014/TTLT-BYT-BTC dated November 24, 2014 of the Ministry of Health and the Ministry of Finance guiding health insurance, the health station may issue a medical record summary in accordance with the template specified in Annex 4 enclosed herewith when the patient is discharged from the health station.
Thus, according to the provisions of Clause 1, Article 17 of Circular 56/2017/TT-BYT above, a medical examination and treatment establishment that has been granted a medical examination and treatment operation license has the scope of professional activities to be licensed. The inpatient license has the authority to issue a summary of the medical record.
Vietnam: What is the medical record summary used for?
Pursuant to the following provisions:
(1) Article 5 of Circular 56/2017/TT-BYT
- Clause 1, Article 5 of Circular 56/2017/TT-BYT is amended by Clause 2, Article 1 of Circular 18/2022/TT-BYT;
- Clause 2, Article 5 of Circular 56/2017/TT-BYT;
- Clause 3, Article 5 of Circular 56/2017/TT-BYT as amended by Clause 3, Article 1 of Circular 18/2022/TT-BYT;
- Clause 4, Article 5 of Circular 56/2017/TT-BYT as amended by Clause 4, Article 1 of Circular 18/2022/TT-BYT;
- Clause 5, Article 5 of Circular 56/2017/TT-BYT as amended by Clause 5, Article 1 of Circular 18/2022/TT-BYT;
- Clause 6, Article 5 of Circular 56/2017/TT-BYT as amended by Clause 6, Article 1 of Circular 18/2022/TT-BYT;
(2) Article 6 of Circular 56/2017/TT-BYT
- Clause 1, Article 6 of Circular 56/2017/TT-BYT;
- Clause 2, Article 6 of Circular 56/2017/TT-BYT as amended by Clause 7 Article 1 of Circular 18/2022/TT-BYT;
(3) Clause 3 Article 18 of Circular 56/2017/TT-BYT
From the content of the above provisions, the summary of medical records is used to make the following records:
- Dossier of first assessment examination due to occupational accident;
- Dossier of first assessment examination due to occupational accident;
- Dossier of first assessment examination due to occupational accident;
- Dossiers of medical examination and assessment to implement the survivorship regime;
- Dossier of medical examination and assessment to enjoy lump-sum social insurance;
- Dossier of re-examination for cases of re-injury due to occupational accidents;
- Dossier of re-examination for cases of re-injury due to occupational accidents;
- Dossier for issuance of certificate of maternity leave.
Circular 18/2022/TT-BYT officially took effect on February 15, 2023.
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