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Old 05-05-2009, 09:54 PM
Location: All around the world.....
2,886 posts, read 7,270,740 times
Reputation: 1043


"Vetresearch" gave you the right advice !!
They make a lot of mistakes since computer entry took over manual charting and being overworked!! (stinks at times)
Always go to ROI and get a copy of all of your medical records, free the first requests
all other ther's some type of fee..
at any rate highlight the errors, which will probably lots of them, depending on the VAMC
so that you can write it in the ammended form for accuracy. If you really pay attention to the progress notes that your PCP/or NP charted you will be surprised and may be irritated.
A social worker did an intake for a speciality post trauma clinic and she was eating candy and nodding out for the entire inake, and I found out 4 mos. later after requesting these records that this "chick" put down that I was suicidal to a question... I was ticked off, this is how I found put about what Vetresearch suggested, getting the records corrected....
This was a major error to me and I found all kind of errors in my treatment plans..outright negligence..it's a pain in the behind
I hope that you have good success
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Old 05-17-2015, 08:04 AM
1 posts, read 481 times
Reputation: 10
Attended a doctors visit with PMC and had a full exam. Husband has a tracheotomy and is on continuous o2. When we looked at MHV a few days ago I noticed that his records had been changed.He was now showing a "Thorocotomy" which is what they do when they crack open your chest wall, and there was no indicator at all about a Tracheotomy. Also one of his conditions in COPD which he continues recieving treatment for outside VA and which has been documented for many years, was entirely removed from the records. I have even brought them copies of the records from outside VA and given them to them.
This is important since i believe the reason he had the lung isssues was related to a military exposure. We are pending a claim as we speak. I will copy and high light the old record and write a formal request for correction.
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Old 05-17-2015, 10:36 AM
8,549 posts, read 9,570,283 times
Reputation: 13360
Originally Posted by lfredrick123 View Post
I will copy and high light the old record and write a formal request for correction.
Contact a VSO like the Disabled American Veterans, Vietnam Veterans of America, Veteran's of Foreign Wars, etc and have them assist you. There is no charge for their assistance and you usually will be assigned to a person who knows what and how to deal with the issue. There is no reason to walk the path yourself when others are willing & able to walk with you.
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Old 05-18-2015, 11:03 PM
903 posts, read 1,152,276 times
Reputation: 1395
I work in a private sector neurosurgery (spine specialists) office and we see PRT on charts all the time, no big deal as long as you had a good reason...which you did. Now, get your primary care doc at the VA to order a new MRI. Based on the results of that you will either be referred to a neurosurgeon for evaluation which will determine if you are a surgical candidate. If your MRI doesn't show anything extraordinary the VA will continue to suggest conservative care, probably physical therapy.

You can walk in with a cane, in a wheel chair, or limp, complain of 24/7 pain all you want to. But you cannot fake the neurological tests and the MRI images that will be administered and it will make you look like a fool if you're faking your symptoms. Tell the truth and get the MRI. If you are a drug seeker and want to have access to narcotics you will eventually be caught. That is the only reason to fake your symptoms.
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Old 04-17-2016, 02:02 PM
1 posts, read 337 times
Reputation: 10
Default My records ruin my life

I have been annoyed for years reading inaccurate statements in my medical records. Mostly done by the MA who do your intake before you see the doctor. I even read poor perception comments about me trying to attract male patients because i would fall down from constant walking due to a side affect from a drug the clinic ask me to try. My discharge summary is exaggerated and inaccurate. Most of the inaccurate information leaves out facts that would point the finger toward malpractice and gross neglect or give reason to deny a claim. Seeing how MA treat a patient, I decided to study Medical Assistant course and learned about ICD-9 codes. First thing I noticed is my therapist did a treatment plan and was told to change it having said I had a history of cannabis abuse . Now that is a bold face lie. I never told anyone that so where did it come from. I noticed it was never changed and saw it again on hospital discharge summary. I'm in the process of filling the form to try to delete it. I hate they require a form for each individual request. Another issue is they require a copy of the record but when you ask for the record they only go back two years. SMH About the ICD-9 codes, i was taught how to pick the right code to describe a diagnosis or treatment. I don't know who wrote my codes but they seem to have taken the easy way out by using the first code they read without going further to give a more accurate description. These codes as they were written leaves out information the regional office could use to decide my claim or another doctor treatment. If I told my doctor the reason I had a bowel resection but the codes says they don't know the reason....something is wrong here. The reason is they made a mistake in removing a normal appendix which lead to adhesions causing my intestines to die. I had a skull fracture but the code says they don't know the reason. I told them how it happen so why not record it accurately. Now I see why claims come back denied due to no information showing SC or not giving the truth . I claimed TBI with test indicating it exist. One symptom of TBI is ringing in the ear but the record wont include it and they call my ear itch " earache" which is not the same. These are two separate concerns. I have degenerative disk in my neck. There is a code for that but they just say neck pain. That's too vague. There are soo many mistakes in my records, I wont be able to correct them all. Most of them are " beyond two years".
My records clearly defames my character and gives a false diagnosis that is unable to treat. Because Im intelligent enough to notice when someone is wrong and complain about it, they rather call it narcisstic to compensate for their blunders. Im too caring of others to be called that. Since my discharge records are over 10 years ago, they still have an impact on my character as being a malinger when in fact, i was suffering from the condition they overlooked and was not treated when they removed a normal appendix. They don't want admit they were wrong by forcing my discharge to get rid of me instead. I should have received an honorable discharge but got a general discharge. You only get one life and Id like to live it truthfully and be treated for as the person I am not someone they make me out to be. It is a said, when a mistake is never corrected, anything the follows after that is also a mistake. The powers at be rather believe what they read instead of what I say.
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Old 08-04-2017, 02:46 PM
Location: El Paso, TX
1 posts, read 130 times
Reputation: 10
Smile Amended records?

I was scared too!! Amended seems to come from Congress, I thought. Hey, thanks for bringing the issue to all concerned. This is what I just found as I was trying to find out what it actually means. Check it on: [FONT=Times New Roman][SIZE=3][/SIZE][/FONT]
[FONT=Arial][SIZE=3]https://www.google.com/search?safe=active&site=&source=hp&q=why+my+VA+rec ords+say+amended%3F&oq=why+my+VA+records+say+amend ed%3F&gs_l=psy-ab.3..33i160k1l3.2437.15761.0.16371. 234.3770.0j28j1.29.0....0...1.1.64.psy-ab..2.26.3416.0..0j35i39k1j0i131k1j0i20k1j0i3k1j0i 22i30k1j33i22i29i30k1j33i21k1.8uCLFtjAbBc[/SIZE][/FONT]
[FONT=Times New Roman][SIZE=3][/SIZE][/FONT][FONT="Times New Roman"]

Originally Posted by VegasGrace View Post
Went to Primary Care and asked for relief of chronic back pain. My doc went through with me all the treatments I have had (shots, tens, crutches, etc). I informed her that the last shot doc gave me 4 shots and said my medical records show that it's my sacril/illiac joint (excuse the spelling). And I express how I feel that is incorrect and the shots have all been 100% ineffective-that I needed further diagnosis and treatment.

The VA computer called me yesterday saying I had an appointment. Showed up and this new doc said - as he was preping a syringe- that my primary care doc sent me to him for shots.

What in the world!!!!!

I spoke with him briefly and he said that all his office does is shots and that helps most veterans. He said what it seems like (after a short exam) is it's my siatic knot (whatever that is). I asked if I were his daughter and he had given me series of shots over the course of years and they were all ineffective-what would he recommend.

The answer was:
a neurosurgeon who will take more MRI (as the last one was long ago and they now have a better machine) and then a treatment plan. He sent me to my primary care for the appointments.

While I was there the nurse read out "patient refused treatment". Then she said my primary care doc would have to speak with this other doc and that I can't refuse treatment like that.

What in the world! The primary care doc sent me to the wrong place!

So now it's in my medical records...so this definitely needs amending.

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