Circular 13/2025/TT-BYT providing guidance on the implementation of electronic medical records

CIRCULAR

Providing guidance on the implementation of electronic medical records

Pursuant to the 2023 Law on Medical Examination and Treatment;

Pursuant to the Government's Decree No. 42/2025/ND-CP dated February 27, 2025, defining the functions, tasks, powers and organizational structure of the Ministry of Health;

At the proposal of the Director of the Administration of Science Technology and Training, the Director of the Department of Medical Services Administration, and the Director of the Agency of Traditional Medicine Administration,

The Minister of Health hereby promulgates the Circular providing guidance on the implementation of electronic medical records.

Article 1. Principles of management and implementation of electronic medical records

1. An electronic medical record refers to a medical record as prescribed in Clause 17, Article 2 of the Law on Medical Examination and Treatment, which is established, updated, displayed, signed, stored, managed, used, and accessed by electronic means.

2. The establishment and update of electronic medical records of patients at medical examination and treatment establishments must ensure full information in accordance with the provisions in Chapter X of the Ministry of Health's Circular No. 32/2023/TT-BYT dated December 31, 202, detailing a number of articles of the Law on Medical Examination and Treatment.

3. The information in the electronic medical record shall be linked to the personal identification number of Vietnamese citizens and foreigners who have been issued electronic identification accounts in accordance with the law on identity.

4. Compliance with the laws on medical examination and treatment, data, information technology, e-transactions, cyber security, cyberinformation security, information access, personal data protection, data storage; and regulations on management, connection and sharing of electronic data of state agencies.

Article 2. Information technology requirements for implementation of electronic medical records

1. Having information technology infrastructure, at least including workstations; network connection infrastructure; servers; data storage solutions or devices (including backup storage); information security equipment and solutions and other relevant equipment.

2. Having information technology applications in the management of medical examination and treatment to implement electronic medical records.

3. Satisfying technical standards on information technology applications in state agencies as prescribed by the law on information technology.

4. Ensuring readiness for restoring information and data and retrieving electronic medical records when necessary for reference, comparison, exploitation, and use in treatment, inspection, examination, scientific research, and health management.

Article 3. Provisions on electronic signature and confirmation in electronic medical records

Medical personnel, patients, or the patients’ representatives shall electronically sign or confirm related contents in the electronic medical records in one of the following forms:

1. Use of a lawful electronic signature;

2. Use of biometric techniques;

3. Use of other forms of electronic confirmation in accordance with Clause 4, Article 22 of the Law on E-Transactions.

Article 4. Effect

1. This Circular takes effect from July 21, 2025.

2. Implementation roadmap

a) Medical examination and treatment establishments licensed to operate as hospitals shall implement electronic medical records no later than September 30, 2025;

b) Other medical examination and treatment establishments providing inpatient, day treatment, and outpatient treatment shall implement electronic medical records and complete such implementation no later than December 31, 2026.

3. The following documents and provisions cease to be effective from the effective date of this Circular

a) The Ministry of Health's Circular No. 46/2018/TT-BYT dated December 28, 2018, on electronic medical records;

b) Section VIII of Appendix I and the evaluation criteria related to electronic medical records under the Minister of Health's Circular No. 54/2017/TT-BYT dated December 29, 2017, on criteria for assessment of information technology application at health facilities.

Article 5. Transitional provisions

1. For patients being treated at medical examination and treatment establishments before the effective date of this Circular and discharged or completing an outpatient treatment session after the effective date of this Circular who are applying paper-based medical records, such paper-based medical records shall continue to be used until the patients are discharged or the outpatient treatment session is completed, except where the medical examination and treatment establishment is capable of converting to electronic medical records.

2. For medical records created in paper form prior to the effective date of this Circular: based on the actual conditions of the medical examination and treatment establishment, the head of the medical examination and treatment establishment shall decide on the conversion between paper documents and data messages, ensuring compliance with the provisions of the Government’s Decree No. 137/2024/ND-CP dated October 23, 2024, defining e-transactions of state agencies and information systems serving e-transactions.

Article 6. Implementation organization

1. Responsibilities of units under the Ministry of Health

a) The Administration of Science, Technology and Training shall assume the prime responsibility for, and coordinate with relevant agencies and units in, directing, urging, guiding, and inspecting the implementation of this Circular nationwide;

b) Departments and Agencies under the Ministry of Health shall organize the development, updating, and guidance of professional contents related to the implementation of electronic medical records according to their assigned functions and tasks;

c) The National Health Information Center shall provide technical guidance on the implementation of electronic medical records in accordance with this Circular and other relevant legal documents.

2. Responsibilities of ministries, sectors and People’s Committees of provinces and centrally-run cities

a) Direct, urge, provide guidance and inspect the implementation of this Circular according to the management;

b) Ensure resources for the implementation of electronic medical records in accordance with this Circular for establishments under their management (excluding private medical examination and treatment establishments).

3. Responsibilities of medical examination and treatment establishments

a) Organize the implementation of electronic medical records in accordance with this Circular and the guidance of competent agencies;

b) Develop and promulgate regulations on the creation, updating, management, storage, use, and information security of electronic medical records, including contents stipulated in Article 3 of this Circular.

Any difficulties arising in the course of implementation should be promptly reported to the Ministry of Health (via the Administration of Science, Technology and Training) for consideration and settlement./.