MEXICO CONTEXT
Artificial intelligence in medicine in Mexico
Artificial intelligence for doctors in Mexico can help prepare notes, organize information, and consult evidence. Its value depends on the note being easy to review and properly integrated into the medical record.
In Mexico, it is advisable to distinguish the tool that generates a draft, the file that documents the care provided, and the SIRES that preserves and exchanges electronic information.
🇲🇽 Mexico
Medical record: NOM-004-SSA3-2012.
Electronic registration: NOM-024-SSA3-2012.
Scope: public, social, and private sectors.
Local term: medical record.
What does NOM-004 require for a clinical note in Mexico?
The NOM-004-SSA3-2012 it establishes scientific, ethical, technological, and administrative criteria for the creation, integration, use, conservation, and protection of the medical record. It does not define a single template for all care, but it makes clear that each record must identify the professional intervention and provide useful information for the continuity of care.
| Identification and context | Sufficient patient, facility, and professional data to link the note to the correct care. |
| Interrogation and medical history | Relevant clinical information, current condition, and background supporting the evaluation. |
| Exploration and results | Relevant findings, vital signs, and available results for the episode. |
| Problems, prognosis and plan | Diagnoses or clinical problems, prognosis, and therapeutic indications in an understandable way. |
| Authorship and opportunity | Date, time, full name, and signature of the person who prepares the note, recorded during or at the end of the care. |
A longer note is not necessarily a better note. Documentation should be sufficient, consistent with the visit, and easy to attribute to the responsible healthcare professional. The Mexican guide to clinical documentation using AI translates these principles into a practical checklist.
FRAME OF MEXICO
From the medical record to the interoperable electronic health record
Mexico regulates healthcare content and the systems that manage it separately. That separation is important when evaluating an AI tool: drafting text does not turn the tool into the official record or a certified exchange system.
NOM-004
It defines the clinical record and the minimum criteria for its notes and documents in doctor's offices, clinics, and hospitals.
NOM-024
It regulates Electronic Health Record Information Systems and their mechanisms for exchange, security, and use of standards.
Health data
They are particularly sensitive information. The controller must determine the applicable regime depending on whether it is a public institution or a private provider.
Responsibility
The establishment and the professional retain their obligations regarding registration, custody, access, and confidentiality even if they use third-party software.
Reference institutes and hospitals in Mexico
Mexico combines national institutes of health, federal hospitals, and state networks. To observe high-specialty practices, teaching, and research, institutions such as the following are especially relevant:
Salvador Zubirán National Institute of Medical Sciences and Nutrition
Mexico City. National Center for High Specialty, Clinical Training, and Research.
General Hospital of Mexico Dr. Eduardo Liceaga
Mexico City. General referral hospital with multiple specialties and teaching activity.
Federico Gómez Children's Hospital of Mexico
Mexico City. National Institute dedicated to specialized pediatric care, teaching, and research.
Ignacio Chávez National Institute of Cardiology
Mexico City. National reference institute for cardiovascular care, education, and research.
Non-exhaustive selection of benchmark public institutions. This is not a ranking nor does it indicate affiliation with Itaca.
Medical record, EHR and SIRES: three distinct levels
The terms are often mixed up, but they describe different objects. Knowing which one is being evaluated prevents asking a support application to single-handedly fulfill functions that belong to the institutional system.
| Element | Main function | Responsibility |
|---|---|---|
| Medical record | Single set of information and documents regarding a person's care. | The establishment maintains and manages the file. |
| Electronic Health Record (EHR) | File stored and managed in electronic media within the establishment. | It is part of the care process and its access controls. |
| SIRES | System that captures, manages, or exchanges electronic health information, including the EHR. | It is subject to the functional and interoperability requirements of NOM-024 when applicable. |
What changes when care is remote or uses AI
Documentation requirements do not disappear simply because the consultation is remote. The professional must be able to identify the patient, record the assessment, and keep the relevant clinical information in the medical record.
In Mexico, not every AI tool serves the same function. An application that drafts a memo must be evaluated differently than a SIRES or software with a diagnostic purpose. The institution must review the intended purpose, access controls, traceability, and the way in which the result reaches the official record.
Scope: This page summarizes national references. Providers must also review the institutional, state, contractual, and professional rules applicable to their service.
Five questions to evaluate a tool
- Can the professional review and correct each result?
- Is it clear where the official file is kept?
- Can access and changes be audited?
- Does the provider explain how they handle health data?
- Does the actual function match what the institution needs?
Where AI can contribute to Mexican clinical practice
The clearest opportunity lies in tasks where the team already invests time in transcribing, organizing, or relocating information. Utility must be measured within the actual workflow of each doctor's office, clinic, or hospital.
Notes and documents
Prepare structured drafts from the conversation and available context.
Consistency
Provide common structures for outpatient clinics, specialties, and multi-site facilities.
Clinical evidence
Search and synthesize medical sources for specific questions, with professional critical review.
Continuity
Organize background information and previous encounters to retrieve relevant context more quickly.
AI does not solve interoperability, document quality, or data protection on its own. It is a support layer that must fit into the institution's controls and systems.
ITACA IN MEXICO
Convert conversations and documents into review-ready clinical notes
Itaca helps turn conversations, documents, and quick notes into structured clinical drafts. It also allows working with templates and longitudinal context depending on the contracted functions.
The professional reviews and approves the content. The office, clinic, or hospital retains responsibility for its medical record, its policies, custody, and integration with its systems.
Official sources for further reading
- NOM-004-SSA3-2012: medical record.
- NOM-024-SSA3-2012: Electronic health record information systems.
- Regulations of the Directorate-General for Health Information.
- Security and privacy in clinical notes with AI.
Editorial and source review: Itaca team. Updated: September 11, 2026. Use this page for initial guidance. Before deciding, confirm the current regulations and your institution's policies.
Frequently asked questions about medical AI in Mexico
Does an AI tool replace the medical record?
No. It can help prepare content, but the official medical record remains under the administration and custody of the health facility.
Do NOM-004 and NOM-024 regulate the same thing?
No. NOM-004 focuses on the medical record and its documents; NOM-024 regulates electronic information systems and health data exchange.
Can AI sign or approve a note on behalf of the physician?
No. The professional must review the draft and assume authorship of the content they decide to include in the file.
Does the same evaluation work for any clinical tool?
No. The purpose, level of risk, data processing, and relationship with SIRES or the institutional file must be reviewed.
Explore other national contexts
Compare how the medical record, data protection, and interoperability change between countries.