Electronic health records

One continuous health record, in the Ministry of Health forms

Each patient has a single record: administrative information, allergies, vital signs, diagnoses, prescriptions and every episode of care. Doctors document according to the medical record template structure, print and sign on the correct form, and the data is ready for national data exchange.

  • Unique patient identifier
  • Medical record templates per TT 32/2023
  • Episode of care timeline
  • HL7 FHIR R4 data standard
clinic.medagents.vn
MedAgents clinic portal: a patient record with the list of episodes of care

MedAgents clinic portal interface

A unified record

The full health picture on a single screen

Instead of searching through several logbooks and software systems, the doctor opens one record and sees the information needed for a clinical decision.

Identity & administration

A dedicated patient ID, with quick search by national ID, phone number, or name; contacts and documents gathered in one section.

Allergies always visible

The allergy alert banner shows severity and the source of the record, and sits at the top of every record screen.

Vital signs across the whole journey

Blood pressure, pulse, temperature, SpO₂, and weight across visits are displayed as tables and charts.

Problems & current medications

A list of the problems being followed by ICD-10 code along with current medications, updated from each episode of care.

Episodes of care & documents

Each episode of care gathers notes, lab tests, imaging, prescriptions, care sheets, and signed documents.

Goals & plans

The doctor sets treatment goals, follow-up visits, and preventive reminders; the team tracks them in the same record.

Clinical documentation

As far as the visit goes, the record goes with it

Notes for each visit follow the sections of the medical record template, so by the end of the episode of care the record already holds enough content to print, sign, and archive.

  • By medical record section: reason for visit, history of present illness, past history, clinical examination, diagnosis.
  • ICD-10 diagnoses: primary and comorbid codes attached to each visit.
  • One episode, all orders: labs, imaging, procedures, and prescriptions stay within the same episode of care.
  • Unsigned item reminders: unsigned drafts are clearly flagged before a new visit is opened.
clinic.medagents.vn
Medical record detail screen: encounter notes following the sections of the record template
clinic.medagents.vn
A preview of the outpatient medical record, form MS 15/BV-01, with the signer flow

Forms & signatures

Medical records in the correct format, signed and printed directly in the system

Recorded data is populated into forms that follow Ministry of Health form codes. Signatories are assigned by role to each signature field on the form.

  • Matches the printed form: a preview by form code, for example MS 15/BV-01 outpatient medical record.
  • Signing flow: the attending doctor and the clinical lead sign in the prescribed order.
  • Download PDF or print: exported from the same data source, with no re-entry.
  • Documents in the episode: visit forms, order forms and results are all viewable in the Documents tab.

Regulatory compliance

Electronic medical records in line with Ministry of Health regulations

MedAgents designs forms, data structures and signing flows that follow current regulations, so facilities can roll out electronic medical records (EMR) and data exchange on schedule.

TT

Circular 32/2023/TT-BYT

Detailed regulations for the 2023 Law on Medical Examination and Treatment · effective 01/01/2024

Medical record templates, certificates, and clinical forms follow the guidance in Official Letter 65/KCB-QLCL&CĐT: 32 medical record templates and 80 certificate and form templates.

On MedAgents: Forms in MedAgents are digitized by form code, for example MS 15/BV-01, and draw data directly from the record.
TT

Circular 13/2025/TT-BYT

Guidance on electronic medical record implementation · effective 21/07/2025

Replaces Circular 46/2018/TT-BYT. Hospitals must complete this before September 30, 2025; other medical examination and treatment facilities before December 31, 2026. Confirmation is by electronic signature, biometrics, or other lawful means.

On MedAgents: Records are created, updated, signed, and stored entirely electronically, with role-based permissions, access logs, and backup and recovery.
QĐ

Decision 130/QĐ-BYT

Standards and XML output data formats for the management, assessment, and payment of medical examination and treatment costs

Includes the summary tables for medical examination and treatment, medicines, technical services and supplies, diagnostic testing, clinical progress, discharge papers and medical record summaries. Amended and supplemented by subsequent decisions.

On MedAgents: Episode-of-care data is structured for export into the XML tables used when a facility applies health insurance (BHYT) billing.
QĐ

Decision 1551/QĐ-BYT

Collection and exchange of health check data and creation of the Electronic Health Book on VNeID · issued 31/05/2026

Data from periodic health checks and screening visits is digitally signed and synchronized to the Ministry of Health personal health database within 24 hours after the episode of care. Appendix 01 on the data template is replaced under Decision 2062/QĐ-BYT.

On MedAgents: Periodic health check certificates and books are structured to the prescribed data template, ready to sync.
  1. 01/09/2023XML data under QĐ 130 used officially for health insurance (BHYT) assessment and payment
  2. 01/01/2024Circular 32/2023/TT-BYT takes effect
  3. July 21, 2025Circular 13/2025/TT-BYT takes effect
  4. 30/09/2025Deadline for hospitals to complete electronic medical records
  5. 31/05/2026QĐ 1551 on health examination data issued
  6. 31/12/2026Deadline for other medical examination and treatment facilities
Clinical data to the HL7 FHIR R4 standardDiagnosis coded in ICD-10Patient identification linked to the citizen ID (CCCD)

This text is summarized for introduction and does not replace the original document. The scope that applies at each facility, such as health insurance (BHYT) billing or synchronization of health check-up data, is confirmed during the implementation discovery session.

Lookup & management

Find the right patient, without creating duplicate records

The front desk and doctors look up the same patient register, according to the permissions granted for each site.

  • Citizen ID first: look up the citizen ID number before creating a new record, to limit duplicates.
  • Medical record list: filter by department, treatment status and episode start time.
  • Custom columns: each role selects the information it needs to see in the list.
  • Legacy data import: reconcile identifiers and duplicate records before migrating from another system.
clinic.medagents.vn
Electronic medical record list with filters by citizen ID (CCCD), record number and status

Data security

Health data protected at every step

Patient records are sensitive data. MedAgents complies with HIPAA, information system security from level 3 upward, and the personal data protection regulations currently in force in Vietnam.

Role-based permissions

Doctors, nurses, and front desk staff see only the part of the record their work requires.

Access log

Every view, edit, and signature is recorded so it can be checked later.

Mask identification numbers

The citizen ID number and the contact phone number are partially masked on screen.

AI supports, the doctor decides

AI summary suggestions are saved to the record only when the doctor confirms them.

FAQ

Frequently asked questions

Are small clinics required to implement electronic medical records?

Under Circular 13/2025/TT-BYT, medical examination and treatment facilities other than hospitals are to complete implementation before 31/12/2026. Each facility should refer to the original document and to Department of Health guidance to determine its own roadmap.

Can MedAgents medical record templates be printed like the paper versions?

Yes. Forms are built to Ministry of Health form codes; doctors can preview, download a PDF, or print directly from the recorded data.

If we already use other software, how are the existing records migrated?

The facility provides the export data structure and the coding rules currently in use. Both sides confirm the fields to migrate and how duplicate records will be reconciled before import.

Can health check data be synchronized to VNeID?

Decision 1551/QĐ-BYT requires data from periodic health examinations and screenings to be synchronized to the Ministry of Health's Personal Health Database. The connection to the facility's account is configured during implementation.

Can patients view their own records?

The facility chooses what is shared with patients, such as results, prescriptions, and follow-up appointments. AI content sent to patients always carries the notice: “This information is for reference only and does not replace advice from a doctor.”

Ready to move to electronic medical records

Share the workflows and forms the facility uses today, and MedAgents will propose an implementation path in line with regulations.

Compliance commitment
  • Data stored on infrastructure in Vietnam
  • Meets National Prescription data exchange requirements
  • Law 91/2025/QH15 · NĐ 356/2025
  • Information security level 3+ · HIPAA
View security & data