Latest guidelines for implementing electronic medical records

(Chinhphu.vn) - The Ministry of Health has issued Circular 13/2025/TT-BYT guiding the implementation of electronic medical records.

Ministry of Health requires hospitals to deploy electronic medical records no later than September 30, 2025

Principles of management and implementation of electronic medical records

According to Circular 13/2025/TT-BYT, electronic medical records are medical records specified in Clause 17, Article 2 of the Law on Medical Examination and Treatment, which are established, updated, displayed, signed, stored, managed, used and exploited by electronic means.

Medical records are a collection of data, including personal information, medical examination results, paraclinical results, functional test results, diagnosis, treatment, care and other relevant information during the patient's treatment process at the medical examination and treatment facility.

The Circular clearly states that the establishment and updating of electronic medical records of patients at medical examination and treatment facilities must ensure full information as prescribed in Chapter X of Circular No. 32/2023/TT-BYT dated December 31, 2023 of the Ministry of Health detailing a number of articles of the Law on Medical Examination and Treatment.

Connecting information of electronic medical records with personal identification numbers of Vietnamese citizens and foreigners who have been granted electronic identification accounts according to legal regulations on identification.

Comply with legal regulations on medical examination and treatment, data, information technology, electronic transactions, network information security, network security, information access, personal data protection, data storage; regulations on management, connection and sharing of electronic data of state agencies.

Information technology requirements for implementing electronic medical records

There is an information technology infrastructure of the medical examination and treatment facility, including at least workstations; network connection infrastructure; servers; data storage solutions or devices (including backup storage); information security devices and solutions and other related devices.

There are information technology applications in medical examination and treatment management to deploy electronic medical records.

Meet technical standards on information technology application in state agencies according to regulations of law on information technology.

Be ready to restore information, data and retrieval capabilities on electronic medical records when necessary for reference, comparison, exploitation and use in treatment, inspection, examination, scientific research and medical management.

Regulations on electronic signature and confirmation in electronic medical records

According to the Circular, medical staff, patients or patients' representatives sign or electronically confirm relevant content in electronic medical records in one of the following forms: 1. Using a legal electronic signature; 2. Using biometric techniques; 3. Using other forms of electronic confirmation as prescribed in Clause 4, Article 22 of the Law on Electronic Transactions.

Hospitals to deploy electronic medical records no later than September 30, 2025

This Circular takes effect from July 21, 2025.

Medical examination and treatment facilities licensed to operate as hospitals must implement electronic medical records no later than September 30, 2025.

Other medical examination and treatment facilities with inpatients, day care and outpatients must implement electronic medical records, to be completed no later than December 31, 2026.

For patients who are being treated at medical examination and treatment facilities before the effective date of this Circular and are discharged from the hospital or finish their outpatient treatment after the effective date of this Circular and are using paper medical records, these medical records will continue to be used until they are discharged from the hospital or finish their outpatient treatment, except in cases where the medical examination and treatment facility can convert them to electronic medical records.

For medical records that have been established in paper form before the effective date of this Circular: based on the actual conditions of the medical examination and treatment facility, the Head of the medical examination and treatment facility shall decide on the conversion of form between paper documents and data messages to ensure compliance with the provisions of Decree No. 137/2024/ND-CP dated October 23, 2024 of the Government regulating electronic transactions of state agencies and information systems serving electronic transactions./.

Source: https://baochinhphu.vn/huong-dan-moi-nhat-trien-khai-ho-so-benh-an-dien-tu-102250610172135659.htm