Decision No. 4069/2001/QD-BYT of the Minister of Health issues medical record and medical chart templates for use in healthcare facilities, applicable to state-owned, semi-state-owned, private non-profit, private for-profit, and foreign-invested hospitals. Leading specialized hospitals may supplement necessary contents upon approval by the Minister.
Scope of application
Healthcare facilities (hospitals), including state-owned, semi-state-owned, private non-profit, private for-profit, and foreign-invested hospitals. Leading specialized hospitals.
Key points
- The Ministry of Health issues medical record and medical chart templates for use in healthcare facilities.
- These templates apply to all types of hospitals, except that leading specialized hospitals may supplement necessary contents upon approval by the Minister.
- The Director of the Treatment Department is responsible for guiding and inspecting the implementation of medical record templates at hospitals nationwide.
- This Decision takes effect from the 15th day following the date of issuance, replacing Decision No. 1333/1999/BYT-QD.
🌐 Social impact of this document
- Positive impact: Standardizing medical records improves the quality of healthcare services and facilitates health monitoring and management processes.
- Negative impact: It may cause difficulties for leading specialized hospitals in supplementing necessary contents.
❓ Frequently asked questions
How do healthcare facilities implement the medical record and medical chart templates?
All state-owned, semi-state-owned, private non-profit, private for-profit, and foreign-invested hospitals must use the templates issued by the Ministry of Health.
What can leading specialized hospitals supplement?
Leading specialized hospitals may supplement certain necessary contents into the templates upon approval by the Minister of Health.
Who is responsible for guiding and inspecting the implementation of medical record templates?
The Director of the Treatment Department of the Ministry of Health is responsible for guiding and inspecting the implementation of medical record templates at hospitals nationwide.
When does this Decision take effect?
This Decision takes effect from the 15th day following the date of issuance, replacing Decision No. 1333/1999/BYT-QD.
When can leading specialized hospitals supplement contents into the medical record templates?
Leading specialized hospitals may supplement certain necessary contents into the templates upon approval by the Minister of Health.
Full text
Pursuant to …;
Regarding the issuance of medical record forms and patient charts
___________
THE MINISTER OF HEALTH
Pursuant to the Law on Health Protection for the People,
Pursuant to Decree No. 68/CP dated October 11, 1993 of the Government stipulating the functions, tasks, authorities, and organizational structure of the Ministry of Health,
At the proposal of the Director of the Treatment Department of the Ministry of Health,
DECISION:
Article 1. We hereby issue medical record forms and patient charts for use in hospitals (attached samples).
Article 2. The models issued together with this Decision shall be applied in state, semi-state, private, and foreign-invested healthcare facilities (collectively referred to as hospitals). Specialized leading hospitals may supplement necessary contents to the models after obtaining the consent of the Minister of Health due to specialized requirements.
Article 3Assign the Director of the Treatment Department of the Ministry of Health to be responsible for guiding and supervising the implementation of medical record forms at hospitals nationwide.
Article 4. This Decision takes effect fifteen days from the date of issuance. Decree No. 1333/1999/BYT-QD dated May 3, 1999, issued by the Minister of Health regarding the issuance of medical record forms and patient charts for use in hospitals, is hereby repealed.
Article 5. The following officials are responsible for implementing this Decision: Director of the Office, Inspector General, Directors of the Treatment Department, Planning Department, other Departments of the Ministry of Health, Director of the Vietnam National Pharmaceutical Administration, Directors of Provincial Health Services under central cities, Hospital Directors, Institute Directors with beds under the Ministry of Health, Heads of Health Services in sectors, Deans of Medical and Pharmacy Universities and Colleges./.
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