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Medical records in Chinese hospitals: what official texts say about who keeps them and how copies are made

Published

The State Council Gazette on the gov.cn site publishes a notice of the National Health and Family Planning Commission and the National Administration of Traditional Chinese Medicine, dated 20 November 2013, that issues the Medical Institution Medical Record Management Provisions (2013 edition).

Effect of the two texts

The provisions say they take effect on 1 January 2014.

The State Council's Regulations on the Prevention and Handling of Medical Disputes say they take effect on 1 October 2018.

Who keeps the record

The provisions say outpatient and emergency records are in principle kept by the patient.

The provisions say that if the medical institution has an outpatient record archive or has set up electronic outpatient records, it may keep them with the consent of the patient or the patient's legal representative.

The provisions say inpatient records are kept by the medical institution.

The provisions say that where the patient keeps the outpatient record, the medical institution should promptly hand the examination and test results to the patient.

The provisions say electronic medical records have the same effect as paper medical records.

The provisions say that where the medical institution keeps outpatient records, they are kept for not less than 15 years from the patient's last visit, and inpatient records for not less than 30 years from the patient's last discharge.

Who may ask the hospital for copies

The provisions say a medical institution should accept applications to copy or view records from the patient or the patient's authorised agent, and from the legal heirs of a deceased patient or their agent.

The provisions say the institution should designate a department or staff member to receive applications for copies.

The provisions say that when it receives an application, the institution should ask the applicant for supporting proof and check the form of the application materials.

The provisions say an applicant who is the patient should provide valid identification.

The provisions say an applicant who is the patient's agent should provide valid identification of both the patient and the agent, together with the statutory proof of the agency relationship and a power of attorney.

What the hospital may copy and how

The provisions say a medical institution may copy items such as the doctor's orders, the discharge record, laboratory reports and medical imaging records for an applicant.

The provisions say that where a record is not yet complete, the completed part may be copied first, and the newly completed part copied once staff have completed the record.

The provisions say copies are made with the applicant present.

The provisions say that once the applicant and the medical institution both confirm the copies are correct, the copies are stamped with the institution's certification mark.

The provisions say the institution may charge a material cost fee for copying records as prescribed.

What the dispute regulations add

The State Council regulations say patients have the right to view and copy materials such as their outpatient records, admission notes, test reports and imaging records, along with other record materials that the State Council health authority specifies.

The regulations say that when a patient asks to copy records, the medical institution should provide the copying service and stamp a certification mark on the copies.

The regulations say the patient or the patient's close relative should be present when records are copied.

The regulations say the institution may charge a material cost fee, and that the fee standard should be made public.

The regulations say that if the patient has died, the patient's close relatives may view and copy records under the regulations.

Questions people ask

Who does the record copying provision name as able to apply?

The provisions say a medical institution should accept applications to copy or view records from the patient or the patient's authorised agent, and from the legal heirs of a deceased patient or their agent.

Does the provision say the applicant must be present?

The provisions say copies are made with the applicant present.

What do the dispute regulations say about fees?

The regulations say the institution may charge a material cost fee, and that the fee standard should be made public.

Sources

Each source above was read on the date shown. This page is an unofficial summary of general administrative information. It is not published by the bodies named above, and it is not medical or legal advice. If it differs from the official pages, the official pages prevail, and rules may change after the check date.

Entry facts come from the hospital’s own pages as read on the dates shown in each source note; this unofficial summary is not medical advice, and the hospital’s current published information prevails. Medical and legal notice