Are students in Vietnam allowed to copy medical records? What are forms of medical records in Vietnam?

Are students in Vietnam allowed to copy medical records?

Pursuant to Article 69 of the Law on Medical Examination and Treatment in 2023 stipulating medical record:

Medical record

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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;

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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.

As regulated above, students of research institutions, training institutions may copy medical records only when obtaining the consent from the safekeeping medical establishments for research purposes.

Note: When using information included in medical records, students must treat such information completely confidential and only use them for the given purposes as registered with the medical establishments.

Are students in Vietnam allowed to copy medical records? What are forms of medical records in Vietnam? - image from internet

What are forms of medical records in Vietnam?

Pursuant to Article 52 of the Circular 32/2023/TT-BYT stipulating regulations on use of medical records and documentation of medical records:

Regulations on use of medical records and documentation of medical records

1. Regulations on use of medical records:

a) Healthcare facilities use medical records in paper and electronic forms.

b) Healthcare facilities that use electronic medical records must ensure that all information fields of the medical records are complete.

2. Regulations on documentation of medical records:

a) Accurately, truthfully, and completely document all information in medical records, medical examination results, subclinical tests, functional tests, diagnosis, treatment, care, and other information related to the patient's treatment process at a healthcare facility;

b) The documentation must comply with the contents and professional instructions that have been issued;

c) Use clear and scientific words, present easily to understand and read. Do not use abbreviations in documents provided for patients, including: summaries of medical records, documents handed over to other healthcare facilities, referral letters for medical examination and treatment, health insurance-covered medical documents, follow-up appointment letters. For abbreviations, they must follow the list of symbols and abbreviations used in medical records that have been developed and issued for uniform use at the healthcare facility;

d) Information in the medical records should clearly show the time and person who documented it.

As regulations above, healthcare facilities may use medical records in following forms:

- Paper forms

- Electronic forms

What are cases of disclosure of information of medical records in Vietnam?

Pursuant to Clause 2 Article 10 of the Law on Medical Examination and Treatment in 2023 stipulating right to respect, health protection and privacy in healthcare:

Right to respect, health protection and privacy in healthcare

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2. Patients’ information contained in medical records, and other information about private life that they have provided to practitioners during the course of medical examination and treatment shall be kept confidential, unless as the patient agrees to share information as permitted by laws, or as specified in clause 3 and 4 of Article 69 herein.

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As regulated above, information of medical records shall be kept confidential, except for following cases:

- The patient agrees to share information as permitted by laws;

- 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;

- Practitioners from other medical establishments may read and copy them with the consent of the safekeeping medical establishments.

- 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;

- 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;

- 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;

- 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;

- Patients’ representatives shall be entitled to medical record summaries upon written request.