The Official Mexican Standards (NOM) are technical regulations of mandatory observance issued by the competent agencies. The purpose of which is to establish the characteristics that the processes or services must meet when they may constitute a risk to the safety of people or damage human health.

As well as those related to terminology and those that refer to its compliance and application.

The NOMs must be reviewed every 5 years from their entry into force

The NOMs on Prevention and Health Promotion, once approved by the National Consultative Committee for Disease Prevention and Control Standardization (CCNNPCE). They are issued and published in the Official Gazette of the Federation and, as they concern sanitary matters, they enter into force the day after their publication.
The NOMs must be reviewed every 5 years from their entry into force. The CCNNPCE must analyze and, where appropriate, carry out a study of each NOM.

When their period expires in the course of the immediately preceding year and, as a conclusion of said review and / or study, they may decide to modify, cancel or ratify them.

NOM of the clinical file in general consultation; NOM-004-SSA3-2012

Do you know her?

According to this rule, the clinical record in general consultation must have:

Clinic history.

It should be prepared by medical personnel and other professionals in the health area. According to the specific information needs of each one of them in particular.

It must have, in the order indicated, the following sections:

6.1.1 Interrogation.- You must have at least: identification card, where appropriate, ethnic group, hereditary-family history. Pathological personal history (including use and dependence on tobacco, alcohol and other psychoactive substances, in accordance with the provisions of the Official Mexican Standard, referred to in paragraph 3.12 of this standard) and non-pathological, current condition (inquire about treatments conventional, alternative and traditional types) and interrogation by devices and systems.

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6.1.2 Physical exploration.– You must have at least: external habitus, vital signs (temperature, blood pressure, heart and respiratory rate). Weight and height, as well as data on the head, neck, thorax, abdomen, limbs and genitals or specifically the information that corresponds to the subject of the dentist, psychologist, nutritionist and other health professionals.

6.1.3 Previous and current results of laboratory, office and other studies.

6.1.4 Diagnoses or clinical problems.

6.1.5 Forecast.

6.1.6 Therapeutic indication.

6.2 Evolution note.

It should be prepared by the physician each time he provides outpatient care, based on the patient’s clinical condition.

It will describe the following:

6.2.1 Evolution and updating of the clinical picture (where appropriate, include abuse and dependence on tobacco, alcohol and other psychoactive substances);
6.2.2 Vital signs, as deemed necessary.
6.2.3 Relevant results of the studies of the auxiliary services of diagnosis and treatment that have been previously requested;
6.2.4 Diagnoses or clinical problems;
6.2.5 Forecast;
6.2.6 Treatment and medical indications; in the case of drugs, indicating at least the dose, route of administration and periodicity.
6.3 Interconsultation Note.
The request must be prepared by the doctor when required and will be recorded in the clinical file. The note must be prepared by the doctor consulted and must have:
6.3.1 Diagnostic criteria;
6.3.2 Study plan;
6.3.3 Diagnostic suggestions and treatment; and
6.3.4 The others indicated in numeral 7.1 of this standard.

6.4 Reference / transfer note.

If required, it must be prepared by a doctor of the establishment and a copy of the clinical summary with which it is sent to the patient must be attached, it will consist of:

6.4.1 Sending establishment;
6.4.2 Receiving establishment;
6.4.3 Clinical summary, which will include as a minimum:
6.4.3.1 Reason for sending;
6.4.3.2 Diagnostic impression (including abuse and dependence on tobacco, alcohol and other psychoactive substances);
6.4.3.3 Therapeutics used, if any.

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