Regulation on medical records management in medical institutions

(chinadaily.com.cn)

Updated: 2014-06-25

a. Patients or their legal representatives

b. Dead patient’s legal heir or agent

18. Medical institutions shall assign a specific department or personnel to deal with applications for medical record replication. They should ask applicants to provide required materials and review them when dealing with the application.

a. If the applicant is a patient, valid proof of patient’s identity is required.

b. If applicant is a patient’s agent, valid proof of patient and agent identities, as well as a legal proof on the relationship between the patient and agent and authorization letter, are required.

c. If applicant is a dead patient’s legal heir, a death certificate, valid proof of the heir’s identity, as well as evidentiary materials proving the dead patient and their legal heir relationship are required.

4. If applicant is agent of a dead patient’s legal heir, a death certificate, valid proof of the heir’s and agent’s identities, as well as evidentiary materials proving the relationship between dead patient and their legal heir and that between the legal heir and agent and authorization letter are required.

19. Medical institutes can replicate medical records for applicants, including temperature chart, doctor’s advice note, resident admit note, operation agreement, anesthesia agreement and record, operation record, seriously ill (dying) patients‘ nursing records, discharge record, blood transfusion informed consent letter, special examination (special treatment) consent letter, pathological and test report, and medical imaging examination data.

20. Government authorities of public security, justice, human resources and social security, insurance, medical accident technical appraisal and commercial insurance companies are entitled to ask for some or all medical records for the purpose of dealing with criminal cases, conducting professional and technical appraisal, and examing the claim of commercial medical insurance after submitting the following evidentiary materials:

a. Administrative and judicial government departments, insurance or medical accident technical appraisal departments provide evidentiary materials for reading and copying medical records

b. Applicant’s own ID proof

c. Applicant’s work certificate (in line with administrative and judicial government departments, insurance or medical accident technical appraisal departments)

Insurance companies should also provide a copy of the insurance contract and evidentiary materials which shows patients or their agents’ agreement on the insurance companies’ application for borrowing the medical record when applying for reading or copying medical records for commercial insurance claim examine. If patients are dead, the insurance contract and evidentiary materials which shows the legal heirs or their agents’ agreement on the insurance companies’ application for borrowing the medical record are required, unless contract or law stipulates otherwise.

21. As required by the Basic Medical Record Taking Standard and the Basic Traditional Chinese Medicine Medical Record TakingStandard, if a medical record has not yet been completed, the applicant can only copy the part that has been completed. After medical staff complete the medical record, the applicant can copy the newly finished part.