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How to sign confirmation in electronic medical records?

(Chinhphu.vn) - When implementing electronic medical records, the patient or the patient's legal representative will have to electronically sign or confirm relevant content in the electronic medical record, instead of signing confirmation in the paper medical record.

Báo Chính PhủBáo Chính Phủ10/07/2025

Ký xác nhận trong hồ sơ bệnh án điện tử như thế nào?- Ảnh 1.

Agricultural General Hospital is one of the pioneering medical facilities that has completely implemented electronic medical records - Photo: VGP/HM

Register for digital signature only once

As a unit that has completely implemented electronic medical records and used patient digital signatures (100%) via electronic signature boards, Associate Professor, Dr. Ha Huu Tung, Director of Nong Nghiep General Hospital, shared that implementing electronic medical records is extremely convenient.

Mr. Ha Huu Tung said that in the past, there were thick medical records, especially those of seriously ill patients, which were hundreds of pages thick; the space for the records (archive) was not enough, and each year the number of records doubled. Only records that had been kept for 10 years were liquidated.

"When deploying electronic medical records, that data is shared by the hospital. Therefore, all departments and rooms of the hospital can view clinical results and consult patients online. This is an extremely convenient point.

Medical staff also do not need to write by hand, which is time-consuming. The results must be printed on paper, and the patient must bring them home for the doctor to read each page for consultation.

It is estimated that each year the hospital can save 6-7 billion VND in money by not having to print films, and the medical records printed on paper will also not have to be printed anymore, saving an additional 2-3 billion VND each year. The archives will be used for other professional purposes," said the Director of the Agricultural General Hospital.

In particular, when implementing electronic medical records, the digital signature of the patient or the patient's legal representative confirming the records is also very important. The leader of the Agricultural General Hospital said that when entering the hospital, people only need to register a digital signature once, this signature will be used until the patient is discharged from the hospital. This is very convenient for patients.

Xanh Pon General Hospital, Hanoi - the first medical facility to implement digital signature on VNeiD for patients, is applying to 100% of inpatients and 3 outpatient clinics in the Examination Department. That means signing medical records can be done on phones with the VNeID application installed.

It is expected that after a period of implementation and evaluation of effectiveness, the Hospital will apply digital signatures throughout the entire medical examination and treatment process.

The patient's digital signature is the last step that the patient must perform after the medical examination. When the digital signature is signed directly on the phone, the patient no longer has to sign the treatment cost statement by hand, helping to save time and reduce paperwork for the patient. In particular, the patient's personal information is better secured, minimizing the risk of forgery or misuse.

Ký xác nhận trong hồ sơ bệnh án điện tử như thế nào?- Ảnh 2.

Hospitals must deploy electronic medical records no later than September 30, 2025 - Photo: VGP/HM

Instructions for patient's confirmation signature on electronic medical records

Recently, the Ministry of Health also issued Circular No. 13/2025/TT-BYT guiding the implementation of electronic medical records. Article 3 of this Circular stipulates that medical staff, patients or legal representatives of patients shall electronically sign or confirm relevant contents in electronic medical records in one of the following three forms:

- Use legal electronic signature;

- Using biometric techniques;

- Use other forms of electronic confirmation as prescribed in Clause 4, Article 22 of the Law on Electronic Transactions.

This Circular takes effect from July 21, 2025. Accordingly, patients who are being treated at medical examination and treatment facilities before this date and are discharged from the hospital or finish their outpatient treatment after July 21, 2025, will continue to use paper medical records until they are discharged from the hospital or finish their outpatient treatment, except in cases where medical examination and treatment facilities switch to electronic records.

Medical records established in paper form before July 21, 2025: based on the actual conditions of the medical examination and treatment facility, the leaders of these facilities will decide to convert the form from paper documents to electronic data if the facility has the conditions, ensuring compliance with the provisions of Decree 137/2024/ND-CP on electronic transactions of State agencies and information systems serving electronic transactions.

Also according to Circular 13/2025/TT-BYT, medical examination and treatment facilities licensed to operate as hospitals must implement electronic medical records no later than September 30, 2025.

Other medical examination and treatment facilities with inpatients, day care and outpatients must implement electronic medical records, to be completed no later than December 31, 2026.

Thuy Ha


Source: https://baochinhphu.vn/ky-xac-nhan-trong-ho-so-benh-an-dien-tu-nhu-the-nao-102250710172805559.htm


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