Electronic medical record: what it is and what the law requires

What it is (and what Mexican law says)

The clinical record is the set of documents where you record the care of each patient: medical history, progress notes, prescriptions, results and consents. In Mexico it is regulated by NOM-004-SSA3-2012, which applies to EVERY health service provider, public or private — from the hospital to the individual office.

The electronic version is contemplated by NOM-024-SSA3-2012, which regulates electronic health record systems: interoperability, information security and safeguarding. A serious clinical record system must be designed around these two standards.

• The record is mandatory for each patient and must be kept for a minimum of 5 years from the last care.
• Medical notes must include date, time and full name of the person who wrote them.
• The patient has the right to a clinical summary of his/her record upon request.
• Health data is SENSITIVE personal data under data protection law: it requires a privacy notice and enhanced security measures.

What changes in your daily consultation

• Complete medical history in seconds: history, allergies, current medication and previous notes with one click, in the office or from your cell phone in an emergency.
• Legible handwriting and medication history — fewer errors, zero lost prescriptions.
• Evolution notes with templates by specialty: captures in 2-3 minutes which by hand takes 10.
• Lab results and images attached to the file, not in a drawer.
• Real continuity between consultations and between doctors from the same center: anyone authorized sees the complete history.

What to demand from a clinical record system

Not all “medical software” delivers. When evaluating, demand:

• NOM-004 and NOM-024 compliance: note structure in accordance with the standard, traceability of who wrote what and when, and inalterability of signed notes.
• Security of sensitive data: encryption in transit and at rest, access control by role, automatic backups and audit log.
• Integrated agenda and reminders: the file connected to appointments, with automatic confirmation by WhatsApp to reduce absences.
• Integrated billing: the query charged and billed (CFDI) in the same flow, without recapture.
• Exportability: being able to remove ALL your files if one day you change systems. Without this, your data is hijacked.

Migrate from paper without dying in the attempt

Realistic migration is not capturing 10 years of paper: it is starting digital today and digitizing backwards only the active. Proven method: start with new patients 100% digitally; At each recurring patient consultation, capture their summary (history, allergies, active diagnoses) in 5 minutes; and scan the relevant history as an attachment.

In 3-4 months, your live operation is complete in digital without having stopped the consultation for a single day. With Aura, the clinical record lives alongside the calendar, WhatsApp reminders, collection and billing — the entire practice operation in a single system. Try 14 days for $14 USD.