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Medical Record Contents


Originally, the medical record existed in abbreviated form to refresh the memory of the family physician who may have known more than patients themselves about familial risk factors and patient's history of disease or conditions. But, because care is now provided by a variety of providers from a variety of locations and the bills are paid by more than one payer, the EMR is used to facilitate familiarity with a patient's status. Therefore the EMR includes much more than physical health information. These records may include information about family relationships, sexual behavior, substance abuse, HIV status, genetic information, and even the private thoughts and feelings that come with psychotherapy. This information is often tied to your social security number and because of a lack of consistent privacy protection in the use of it, the information may be easily accessible.

This information from your medical records may influence your credit, admission to educational institutions, and employment. It may also affect you getting health insurance or the rates for your coverage. More importantly, having others know your most intimate details of your life may mean loss of dignity.