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Re: What is and is NOT the medical record?
In a message dated 96-08-27 16:03:49 EDT, you write:
<< Are tissue samples, x-rays, fetal monitor strips, ultrasound videotapes
the like which are external to the "medical record proper," but which
information about the patient and the patient's treatment, part of the
"medical record"? >>
I have an even greater debate here. Does PERSONAL data, such as sexual
history, personal 'dirty laundry', family problems, marital woes, and other
information bear the same "medical weight' as MRI's, CT-Scans, and x-rays?
MRI's and X rays are objective findings. They are fact. Discussions and
interpretations of personal matters is another deal altogether. When I read
MY medical files last year, you would have thought you were reading about
someone other than me. There was NO mention made of my academic achievments,
my top notch performance records at every job ever held, the fact that I made
officer in 2 years (it normally takes 4) at a U.S. Army military academy
(where I ranked in the top 2% of the academic AND military science
curriculums). There was no mention made of my 3 months time donated (without
pay) to the Red Cross, the American Heart Association, the United Way, and
It was all slanted the other way.