Information about patients in the medical examination and treatment management information system in Vietnam from January 1, 2027

Information about patients in the medical examination and treatment management information system in Vietnam from January 1, 2027​ (Image from Internet)

On November 16, 2024, the Minister of Health of Vietnam issued Circular 38/2024/TT-BYT regulating the development, management, exploitation, and use of the Health Examination and Treatment Management Information System.

Information about patients in the medical examination and treatment management information system in Vietnam from January 1, 2027

According to the regulations in Article 8 of Circular 38/2024/TT-BYT, patient information after the conclusion of health examination and treatment for the purpose of state management of health examination and treatment, disease prevention, accounting costs and utilized resources in health examination and treatment are stipulated on the Health Examination and Treatment Management Information System, including:

- Information about patients discharged (for all patient categories):

+ Residential data: full name, date of birth, gender, ethnicity, occupation, personal identification number, or health insurance card number;

+ Address information: place of permanent residence, current residence according to identity card/identity card, contact phone number;

+ Hospital admission, discharge, transfer information: admission date and time, discharge date and time, discharge condition, treatment results, children's weight, number of intensive care or critical care bed days, name of the medical facility (transferred from), name of the medical facility (to be transferred to);

+ Performed surgery, procedures with ICD-9 CM codes (if any) including surgeries, procedures covered by health insurance and those self-paid by the patient;

+ Definite diagnosis upon discharge, including principal disease, complications, accompanying diseases, causes, other related health conditions under ICD-10 code;

+ Main cause of death (for death cases) according to the guidance on establishing the disease chain and events leading to death.

- Detailed information on medication, technical services: list of medications, quantity, unit of measure used including both those covered by health insurance and self-paid medications.

- Results of several clinical and paraclinical indices valuable in diagnosis, prognosis, monitoring.

- Summary of the treatment process for inpatients, transferred patients, and other related subjects to interconnect data into the electronic health book serving continuous care:

+ Medical history (allergies, chronic diseases, surgical history, obstetric history, artificial implant devices), disease history, condition at admission;

+ Clinical progression during treatment;

+ Condition at discharge, treatment results;

+ Summary of paraclinical results, monitoring indices valuable for diagnosis, follow-up, prognosis;

+ Summary of treatment methods applied, medical treatment, surgery, rehabilitation, traditional medicine;

+ Subsequent treatment plan, outpatient prescription, doctor's advice, next appointment schedule;

+ Contact information with the treating doctor or medical facility.

Principles for exploiting and using the health examination and treatment management information system in Vietnam from January 1, 2027

The principles for developing, managing, exploiting, and using the Health Examination and Treatment Management Information System are specifically outlined in Article 2 of Circular 38/2024/TT-BYT including:

- The Health Examination and Treatment Management Information System is built, managed in a centralized, unified, and synchronized manner from the central to local levels.

- The Health Examination and Treatment Management Information System is constructed and updated to provide complete, accurate, and promptly information on health examination and treatment activities, meeting the requirements for state management of health examination and treatment activities.

- The Health Examination and Treatment Management Information System is maintained to operate continuously, stably, smoothly, and stored long-term, meeting the exploitation and use needs of agencies, organizations, and individuals as prescribed by law.

- The development, update, management, exploitation, and use of the Health Examination and Treatment Management Information System comply with legal regulations on information technology, electronic transactions, network information security, cyber security, information access; regulations on management, connection, and sharing of digital data of state agencies; regulations on personal data protection and privacy rights as per current regulations.

- Use of the identification codes assigned by national databases, other specialized databases.

Refer to the Circular 38/2024/TT-BYT (effective from January 1, 2027).

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