Unofficial translation
In accordance with paragraph 9 of Article, 86 of the Code of the Republic of Kazakhstan “On Public Health and the Healthcare System”.
Footnote. The preamble is in the wording of the order of the Minister of Healthcare of the Republic of Kazakhstan dated 13.03.2024 № 9 (shall be enforced from 01.01.2025).1. That the attached Rules for Issuing, Record-Keeping and Maintaining Personal Health Record Books shall be approved.
2. That the following shall be declared null and void:
1) Order № 126 of the Acting Minister of National Economy of the Republic of Kazakhstan of February 24, 2015 “On Approval of the Rules for Issuance, Record-keeping and Maintenance of Personal Health Record Books” (registered with the Register of State Registration of Regulatory Legal Acts under № 10638, published in Adilet, the information and legal system on May 18, 2015);
2) paragraph 3 of Order № 168 of the Minister of Healthcare of the Republic of Kazakhstan of April 12, 2018 “On Approval of the Rules for Hygienic Training of Persons of the Decretized Group of Population and the Programmes of Hygienic Training of Persons of the Decretized Group of Population and Amending Order of the Acting Minister of National Economy of the Republic of Kazakhstan № 126 of February 24, 2015 “On Approval of the Rules for Issuing, Record-Keeping and Maintaining Personal Health Record Books” (recorded in the Register of State Registration of Regulatory Legal Acts under № 16929, published in the Reference Control Bank of Regulatory Legal Acts of the Republic of Kazakhstan on June 16, 2018).
3. That to the extent permitted by the applicable law of the Republic of Kazakhstan, the Committee for Sanitary and Epidemiological Control of the Ministry of Healthcare of the Republic of Kazakhstan shall:
1) ensure the state registration hereof with the Ministry of Justice of the Republic of Kazakhstan;
2) place this order on the website of the Ministry of Healthcare of the Republic of Kazakhstan;
3) within ten working days after state registration hereof, submit to the Legal Department of the Ministry of Healthcare of the Republic of Kazakhstan the information on execution of actions stipulated by sub-paragraphs 1) and 2) of this paragraph.
4. That the supervising Vice-Minister of Healthcare of the Republic of Kazakhstan shall be charged with control over execution hereof.
5. That this order shall come into effect ten calendar days after the date of its first official publication.
|
Minister of Healthcare of the Republic of Kazakhstan |
A. Tsoy |
| Approved by order of the Minister of Healthcare of the Republic of Kazakhstan № KR DSM-196/2020 dated November 16, 2020 |
Rules for issuing, recording and maintaining personal medical records
Footnote. The rules are in the wording of the order of the Minister of Healthcare of the Republic of Kazakhstan dated 13.03.2024 № 9 (shall be enforced from 01.01.2025).
Chapter 1. General provisions
1. These Rules for issuing, recording and maintaining personal medical records (hereinafter - the Rules) have been developed in accordance with paragraph 9 of Article 86 of the Code of the Republic of Kazakhstan "On Public Health and the Healthcare System" and shall determine a unified procedure for the issuance, recording and maintenance of personal medical records.
2. The following concepts are used in the Rules:
1) a personal medical record (hereinafter - a PMR) is a personal document that contains the results of mandatory medical examinations with a mark on admission to work, completely reproducing the appearance and information (data) in electronic digital form;
2) personal medical record module (hereinafter - a PMR module) is an information block of the medical information system intended for registration, storage, transmission, search, distribution, use and recording of a personal medical record;
3) medical information system (hereinafter - MIS) – an information system ensuring the management of processes of healthcare entities in electronic format, with the provision of functionality to laboratory information systems and/or ensures the provision of services to a medical organization for interaction with a laboratory information system used in a medical organization.
Chapter 2. Procedure for issuing a personal medical record
3. The PMR shall be issued with a mark on admission to work and shall be certified by means of an electronic digital signature (hereinafter -the EDS) of the employee and the QR code of the healthcare entity.
4. The PMR shall be issued by medical organizations, regardless of the form of ownership and departmental affiliation, that have a license for medical activities and are registered in the information system management System of resources.
5. By decision of the head of the healthcare entity carrying out mandatory medical examinations, a person responsible for the execution/improper execution of the record, maintenance and issuance of the PMR (therapist) (hereinafter -a specialist) shall be appointed based on the results of the mandatory medical examination and laboratory tests.
6. Information about identity documents shall be transferred to the PMR module by synchronization from the relevant state information systems. If the information systems do not contain the relevant information, the data shall be entered manually.
7. The results of medical examinations and laboratory tests shall be transferred to the PMR module by synchronization from the MIS, in accordance with Appendix 1 to the Rules.
8. When diagnosing an infectious or parasitic disease, as well as identifying the carriage of pathogens of infectious diseases that are a contraindication to admission to work, the specialist refers the owner of the PMR for treatment to the appropriate medical organization providing primary health care at the place of residence.
Chapter 3. Procedure for recording and maintaining a personal medical record
9. The PMR shall be recorded in an electronic registration log in the MIS, using the form in accordance with Appendix 2 to the Rules.
10. The PMR shall be filled out at the choice of the PMR owner in the Kazakh or Russian languages.
11. The photograph of the PMR owner shall be transferred to the PMR by synchronization from the relevant state information systems, and shall be secured with a QR code of the healthcare entity where the medical examination is carried out. If there is no photograph in the information systems, it shall be entered manually from media.
12. The passport data indicates information about the PMR owner according to the identity card or passport.
13. The information about the PMR owner indicates the profession and position, place of work, date of birth, place of residence.
14. Information about previously suffered infectious diseases shall be transferred to the PMR by synchronization from the MIS.
15. Based on the results of the medical examination, the therapist, indicating the surname, name and patronymic (if any) (hereinafter - the full name), shall make a conclusion, which is secured by his/her personal digital signature.
16. The results of the X-ray examination and the conclusion of the specialist doctor, secured by his/her digital signature, shall be transferred to the MPR by synchronization from the MIS.
17. The result of laboratory tests for venereal diseases and the conclusion of the dermatovenereologist, secured by his/her digital signature, shall be transferred to the PMR by synchronization from the MIS.
18. Information on preventive vaccinations shall be transferred to the PMR by synchronization from the MIS.
19. The results of tests for the carriage of pathogenic staphylococcus, for helminth eggs, bacteriological tests and examination for markers of viral hepatitis, HIV shall be transferred to the PMR by synchronization from the MIS. The specialist shall enter a conclusion, which is secured by his/her personal digital signature.
20. The PMR indicates the dates of admission to work, indicating the full name (if any), the specialist's digital signature and the QR code of the healthcare entity.
21. If an incorrect entry of information is detected, corrections shall be made by the employee of the healthcare entity who made the corresponding entry, certified by his/her personal digital signature.
| Appendix 1 | |
| to the Rules for issuing, maintaining | |
| and recording personal medical records | |
| Sample |
Personal medical record
Section 1. Passport data
Photo
Seal
1) Surname________________________________________________________
2) Name________________________________________________________
3) Patronymic (if any) _______________________________________
4) ______________ № ____________________________________________
/series/ number
5) Owner's personal signature_____________________________________
Personal medical record series № _______________________
Personal medical record
Section 2. Information about the owner of the personal medical record
1) Main profession____________________________________________
2) Position___________________________________________________
3) Place of work _________________________________________________
4) Date of birth _________________________________________
5) Place of residence _________________________________________________
Personal medical record
Section 3. Information about previous infectious diseases
Previous infectious diseases
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Personal medical record
Section 4. Result of medical examination, therapist
Date | Doctor's conclusion | Full name, signature and seal of the organization (if any) who conducted the medical examination |
Personal medical record
Section 5. Tuberculosis test results
Date | Doctor's conclusion based on the results of laboratory tests and medical examination | Full name, signature and seal of the doctor (if any) who conducted the medical examination |
Section 6. Result of medical examination and laboratory testing for venereal diseases, dermatovenerologist
Date | Doctor's conclusion based on the results of laboratory tests and medical examination | Full name, signature and seal of the doctor (if any) who conducted the medical examination |
Section 7. Information on preventive vaccinations
Vaccination against infectious disease ______________
Date of administration of the drug " " ___________year
Personal medical record
Section 8. Results of the test on carriage of pathogenic staphylococcus
Date | Doctor's conclusion | Full name, signature of the doctor who conducted the examination and the organization's seal (if any) |
Section 9. Helminth egg test results
Date | Doctor's conclusion | Full name, signature of the doctor who conducted the examination and the organization's seal (if any) |
Section 10. Result of bacteriological test
Date | Doctor's conclusion | Full name, signature of the doctor who conducted the examination and the organization's seal (if any) |
Section 11. Result of examination for markers of viral hepatitis, HIV
Date | Doctor's conclusion | Full name, signature of the doctor who conducted the examination and the organization's seal (if any) |
Section 12. Mark on certification of knowledge of regulatory legal acts of the Republic of Kazakhstan in the field of sanitary and epidemiological welfare of the population and hygienic standards
Date | Certification mark | Full name, signature of the head of the organization that conducted the training and certification, seal (if any) |
Section 13. Admission to work
Date | Permit to work "___" __________ date, month, year | Full name, signature of the responsible specialist of the healthcare entities, seal (if any) |
| Appendix 2 | |
| to the Rules for issuing, maintaining | |
| and recording personal medical records | |
| Form |
Journal of recording personal medical records
No s/n | Full name of the owner of the personal medical record | Place of work, position | Place of residence | Personal medical record number | Admission mark |
1 | 2 | 3 | 4 | 5 | 6 |