What is a case history dossier? Instructions for making case history dossiers in Vietnam

What is a case history dossier? Instructions for making case history dossiers in Vietnam (Internet image)

Regarding this issue, LawNet would like to answer as follows:

1. What is a case history dossier?

According to Clause 1, Article 59 of the Law on Medical Examination and Treatment 2009, case history dossier is a medical, health and legal record. Each patient has only one case history dossier at each time of medical examination and treatment at a medical examination and treatment establishment.

2. Instructions for making case history dossier in Vietnam

Clause 2, Article 59 of the Law on Medical Examination and Treatment 2009, the case history dossiers shall be made as follows:

- Case history dossiers shall be made for all patients receiving inpatient or outpatient treatment at medical examination and treatment establishments;

- Case history dossiers shall be made in hard or soft copies with all items filled in clearly and fully;

- A case history dossier comprises documents and information on the patient and the medical examination and treatment process.

3. Regulations on preserving case history dossiers in Vietnam

Case history dossiers shall be preserved as follows:

- Case history dossiers shall be preserved according to the levels of confidentiality under the law on protection of state secrets;

- Case history dossiers of inpatients and outpatients shall be preserved for at least 10 years; case history dossiers of victims of labor and daily-life accidents shall be preserved for at least 15 years: case history dossiers of mental and dead patients shall be preserved for at least 20 years;

- Medical examination and treatment establishments that preserve case history dossiers electronically shall have backup copies and comply with the regulations above.

4. Who is allowed to access case history dossiers in Vietnam?

The head of a medical examination and treatment establishment shall permit the use of case history dossiers in the following cases:

- Trainee students, researchers and practitioners of medical examination and treatment establishments borrowing case history dossiers for on-the-spot reading or for copying for research or professional purposes;

- Representatives of health state management agencies that directly manage medical examination and treatment establishments, investigative agencies, procuracies, courts, health inspectors, insurance agencies, forensic and mental forensic examination organizations and lawyers borrowing case history dossiers for on-the-spot-reading or for copying for performance of their assigned tasks according to their vested powers:

- Patients or their representatives receiving brief summaries of case history dossiers under Clause 1. Article 11 of the Law on Medical Examination and Treatment 2009.

Note: When using information of case history dossiers, the users specified in Clause 4 of Article 59 of the Law on Medical Examination and Treatment 2009 shall keep it confidential and may use it only for the purposes reported to heads of medical examination and treatment establishments.

5. Patient's rights to respect for privacy in Vietnam

- Article 8 of the Law on Medical Examination and Treatment 2009 stipulates that patients have the right to have their health status and private information given in their case history dossiers kept confidential.

Their health status and private information given in their case history dossiers may be disclosed only when so agreed by patients or for exchange of information and experience between practitioners directly treating the patients to improve the quality of diagnosis, care and treatment of patients or in other cases provided by law.

- Article 11 of the Law on Medical Examination and Treatment 2009 stipulates that patients have the right to receive brief information on their case history dossiers when so requested in writing, unless otherwise provided by law.

To be provided with information on charges for medical examination and treatment services and detailed explanations about expenses indicated in invoices for medical examination and treatment services.

Nhu Mai

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