Regulation on medical records management in medical institutions

(chinadaily.com.cn)

Updated: 2014-06-25

22. Medical institutions should assign a specific department or personnel to inform medical record management department or personnel and send record copies to a designated place within a regulated period of time. The copy should be made with applicants on hand. Copies will be stamped after applicants and medical institutes confirm the whole operation.

23. Medical institutes can charge fees for costs of copying medical records.

Chapter V: Medical record sealing and unsealing

24. Medical institutions or their authorized agents, patients or their agents should be present, jointly confirm medical records, and sign and seal medical record copy if the record needs to be sealed.

When applying to seal medical records, medical institutions should inform patients or their agents to jointly carry out the sealing action. If patients or their agents refuse or give up sealing medical records, medical institutions can confirm medical records with the presence of notary organizations, which sign and seal medical record copies.

25. Medical institutes are responsible for taking care of medical record copies.

26. The original copy can continue to be used after sealed.

As required by the Basic Medical Record Taking Standard and the Basic Traditional Chinese Medicine Medical Record Taking Standard, if medical records have not yet been completed, only the part that has been completed can be sealed. After medical staff complete the medical record, the newly finished part can be sealed.

27. All parties at the scene of signing and sealing medical records should be present when unsealing the record.

Chapter VI Medical record preservation

28. Medical institutions can use micrographics technology that meets file management requirements to deal with paper medical records before preserving them.

29. Preservation time for outpatient (emergency) medical records in medical institutes should be no less than 15 years from the last time patients seek consultation and treatment on. Preservation time for hospitalization medical records should be no less than 30 years since the last time patients are discharged.

30. If a medical institution changes its name, its medical records shall be kept by the medical institution with the new name.

If a medical institution is revoked, its medical records should be handed over to the provincial health and family planning authorities, traditional Chinese medicine administrative authorities, or assigned institutes for preservation.

Chapter VII Bylaws

31: The provisions are explained by the National Health and Family Planning Commission.

32. The regulation takes effect on Jan 1, 2014. The Regulation on Medical Record Management at Medical Institutes issued by the defunct Ministry of Health and the State Administration of Traditional Chinese Medicine (No 193) in 2002 have been abolished.