Regulation on medical records management in medical institutions

(chinadaily.com.cn)

Updated: 2014-06-25

A medical record shall be bound and saved in the following order: home page of hospitalization medical record, record on course of disease, preoperative discussion record, operation agreement, anesthesia agreement, pre-anesthesia visiting record, operation safety verification record, inventory record, anesthesia record, operation record, post-anesthesia visiting record, record on post-operation course of disease, discharge record, death record, death case discussion record, blood transfusion informed consent letter, special examination (special treatment) consent letter, consultation record, critically ill notice, pathological files, auxiliary examination report, medical imaging examination data, temperature chart, doctor's advice record, and seriously ill (dying) patient nursing records.

Chapter III Medical record keeping

10. In theory, outpatient (emergency) medical records should be kept by patients. Medical institutes that have established an outpatient (emergency) medical record room or electronic medical record can take care of medical records after getting approval of patients or their legal representatives.

Hospitalization medical records should be kept by medical institutes.

11. Medical institutes should hand test results over to patients if patients are holding the outpatient (emergency) medical record.

12. Medical institutes should add test results in outpatient (emergency) medical record within 24 hours and put the record on file the first working day after the diagnosis and treatment, if they keep the record.

13. The medical record should be kept by the inpatient department during hospitalization. The inpatient department should assign specific staff to carry and take care of the medical records if they have to be taken away from the jurisdictions of inpatient department for medical activities or work reasons.

The medical institution shall add test results and related information on hospitalized patients in hospitalization medical records within 24 hours after receiving them.

Hospitalization medical records should be kept and managed by the medical records management department or professional (part-time) employees after patients are discharged.

14. Medical institutions shall conduct strict management on medical record. No one can arbitrarily alter, fake, conceal, destroy, rob or steal medical records.

Chapter IV Medical record lending and replication

15. No organization or individual shall have access to a patient’s medical record, except medical staff providing medical services to patients, the health and family planning authorities, Traditional Chinese Medicine authorities, or medical record management and personnel authorized by medical institutions.

16. Other medical institutions and medical personnel that need to read and borrow medical records for scientific research and teaching purposes shall apply to medical institutions. They should return medical records in three working days. The borrowed medical information should not be taken away from the medical institution.

17. Medical institutions should accept applications from the following personnel and organizations for copying or reading medical records, and offer medical record copying and reference services in accordance with relevant provisions: