Mexican Medical Treatment and Your Medical Records NOM-004-SSA3-2012

Mexican Medical Treatment and Your Medical Records NOM-004-SSA3-2012

Many people come to Mexico for medical procedures or already live here and take ill or injure themselves and need the services of a doctor or hospital.
In most cases people are happy with the services provided and they go on living their lives.

A problem arises when a patient wants to obtain their medical records from their doctor or hospital. We have found that many doctors and hospitals are reluctant to give patients their medical records due to fear of lawsuits, sloppy record keeping that does not comply with the law or general laziness. This can often place the patient's life in jeopardy as oftentimes these records are requested for use by other medical professionals for surgeries or other procedures which are urgent and the hospital or doctors place many roadblocks for the release of records.

This article will focus on patient rights and doctor and hospital responsibilities and obligations. The right of a patient to request a full copy of their medical file (and not some quick summary made up by the doctor or hospital) is a human right under Mexican and international laws. The Mexican Constitution guarantees health rights in articles 1 and 4 as well as in international treaties such as part 25 of the Universal Declaration of Human Rights and article 12 of the International Covenant on Economic, Social and Cultural Rights. Mexico publishes official guidelines for a number of products and services and they are called NOMs (Norma Oficial Mexicana). There is a specific NOM, NOM-004-SSA3-2012 regulating the handling of medical files and patient´s rights to receive their medical file and exactly what it should contain. The NOM can be found here: http://dof.gob.mx/nota_detalle.php?codigo=5272787&fecha=15/10/2012

The above mentioned NOM in section 5.4 states that the patient who gives information as well as the person who receives medical attention has ownership rights over the information for the protection of their health as well as the protection of the confidentiality of their information in the terms of this law and others.

Some doctors refuse to give records saying they do not have anything even though a year or two has passed or even less from the last visit, this would be a violation of the NOM which in the 2nd paragraph of section 5.4 states that "due to the foregoing, for documents prepared in the interests of and for the benefit of the patient, they shall be kept for a minimum period of 5 years starting from the last medical act."

Sections 5.5.1 and 5.6 state that any requests for medical information must be made in writing and only given to third parties when requested by the patient, guardian, legal representative or another doctor authorized by the patient, guardian or legal representative. If you are living outside Mexico you can grant a power of attorney to someone to be able to request the records on your behalf.

Many times when a patient asks for their medical records they are given a one sheet summary instead of their medical file. Section 6 to 6.4.3.3 of the NOM clearly explains what makes up the clinical file for general and specialty consultations.

The NOM states that the clinical file must contain a clinical history, questionnaire with family and substance history, physical exploration, prior and current results of laboratory studies and tests and others, diagnosis or clinical problems, prognosis, recommended therapy , progress notes.

As well as the aforementioned, for each doctor visit the following information should be gathered: evolution and update of the clinical profile (including any substance abuse or tobacco use), vital signs as necessary, relevant results of any tests done or diagnosis and treatment that were previously requested, diagnostic or clinical problems, prognosis, treatment and medicines prescribed, for medicines note at the very least the dose, how administered and how often.

Medical notes for hospitalization must contain at a minimum: vital signs, questionnaire, physical exam and mental state as needed, test and lab results, treatment and prognosis, clinical history, evolution notes and should be prepared daily by treating physician.

There are other requirements in the NOM for postop medical reporting.

As you can see the records required to be kept are quite detailed. The problem we have seen is that few doctors are aware of the NOM and their obligations to keep detailed records or visits and tests. Doctors and hospitals may only make you put your request in writing and not put any other further conditions on your request for your medical records although for hospitals you may want to put the approximate date of admittance so they can more easily locate your records. If they place more restrictions you may complain to the State / Federal Medical Arbitration Board (CONAMED) or your state agency that oversees doctors and hospitals. We have experienced doctors and hospitals refusing to accept written requests so then we filed complaints with the aforementioned agencies and then all of the sudden they complied. This is your health and your life and the law, do not let them bully you or wear you down when it comes to requesting your medical records. Do not let them give you a one page summary instead of copies of tests, lab results, EKGs and the like so that another doctor or hospital can read them and diagnose you or view the development or recovery of your illness.

A good practice would be to sit down with your doctor to make sure they are aware of the NOM so that if they are not, then can start to keep proper, complete medical records to provide to you or another doctor in the future. An even better practice would be to request and maintain records in an accessible place in your home so your family will know where they are in the event you are in an accident or hospitalized and need to access them.

Thank you, Intercasa, for this extensive information on a patient's right to receive his or her medical records. With one exception I've been very happy with the level of medical care I've received in Mexico over the past ten years.

I am planning to come to lake Chapala in several weeks. I am gathering my primary care DR's lab reports for past 3 years, and immunization and office visit comments. No major health problems, just high blood pressure treated with HZST, Amlopodine, and Atenolol . Are these drugs available in Lake Chapala and is DR prescription from US needed? Also have dermatologist's records and shoulder replacement's records.
Is there any other records I should bring. These are my US doctor's records.
Thanks, BB

I am not familiar with HZST, but yes, Amlopodina, and Atenolol are readily available over the counter. No prescription needed; just ask for the medication.
In Mexico, your new Cardiologist and Dermatologist (I suggest those at Quality Care Medicos Especialistas, which you can Google) will go over your US history with you. For an Orthopedist, I suggest Dr. Jorge Gonzales at Clinica Maskaras.
Enjoy your move.

RVGRINGO wrote:I am not familiar with HZST, but yes, Amlopodina, and Atenolol are readily available over the counter. No prescription needed; just ask for the medication.  
In Mexico, your new Cardiologist and Dermatologist (I suggest those at Quality Care Medicos Especialistas, which you can Google) will go over your US history with you.  For an Orthopedist, I suggest Dr. Jorge Gonzales at Clinica Maskaras.
Enjoy your move.

Thank You RVGRINGO, for your reply. The HZT pill ( I mistyped HZST) is like a diuretic water pill. This was the first pill I was prescribed when my hypertension was first noted. I have not reached the point where I need a cardiologist yet. My primary care MD has the blood pressure under control with the meds. No bad EKG's yet. I should lose weight and walk, not ride, playing golf.
With my current US health plan, I get these 3 pills, 90 day supply for FREE! I will bring them with me in the prescription bottles.
Fortunately, my shoulder replacement surgeries, both shoulders, has turned out very well, can swing golf club with no pain and fairly good mobility. I plan to walk more and bike ride when I get to Lake Chapala.
BB

You can buy Furosimida (Generic Lasix) in Mexico. Your current medication is probably also available, but either will do the job, as your MD can advise.

I think you mean HCTZ (Hydrochlorothiazide), it is readily available here and all your meds are very economical. They will not be free, though.

Trailrunner wrote:I think you mean HCTZ (Hydrochlorothiazide), it is readily available here and all your meds are very economical. They will not be free, though.

Thanks Trailrunner, That is what I tried to refer to. At least I got some good news on this. I contacted my current health insurance co. It is a medicare supplement that is just in Saint Louis area. They said I am covered for up to 6 months but just for urgent care or emergency room in MX. I guess I address medical insurance if I decide to stay in Lake Chapala.
Smiles, BB

If you decide to live here, it might be good to bring your latest dental xrays, especially if you've had extensive work done.

Gamina wrote:If you decide to live here, it might be good to bring your latest dental xrays, especially if you've had extensive work done.

Thanks, I do have those to bring with me. BB

I'm going to contribute to the one way bus ticket outta Dodge.