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Old 01-14-2009, 08:22 AM
 
1,492 posts, read 6,434,158 times
Reputation: 1410

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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.

How?
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Old 01-14-2009, 09:57 AM
 
7,100 posts, read 22,681,316 times
Reputation: 7165
"patient refused treatment" is a quick way of explaining that you decided that you didn't want the shot and didn't get one. It doesn't mean that you kicked up a fuss about it. It's sort of a doctor speak way of saying that you, and not the doctor, made the decision to skip the injection.

Then, if something goes wrong because you didn't get it, it's your fault, not the doctor's. Doctor's seldom put in the chart everything that was said. If they did, charts would weigh a ton. PRT is shorthand for we talked about it, and the patient said no.

The next time you see a doctor, explain in your own words what was said and done. Don't leave it up to your chart to do it.
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Old 01-14-2009, 11:45 AM
 
48,526 posts, read 75,136,468 times
Reputation: 17823
It means nothing really. But yoyu need to be referred to a specailist that can discusss the various treatmjent options from shots to surgery.Sounds like your doctor referrred to to a very limited specailist for specific treatment.
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Old 01-14-2009, 01:52 PM
 
Location: So. of Rosarito, Baja, Mexico
6,458 posts, read 16,604,482 times
Reputation: 5712
I'm a little puzzeled. I have had excellent care at the VA in San Diego.
My primary care does evaluate my concerns and enters the info on the computer where I later receive an appointment to see the specialist...who further checks my problem.
In SD they have a clinic for different problems in the AM and PM five days a week. Every person has a similiar problem at the same time of the appointment time. When I'm there for my back problem (had a Laminectomy) others were there also wearing their back brace.
You may have a sciatic nerve problem or pinched nerve in the L3/L4/L5 region. It may take 2-3 MRI scans to narrow the spot. They don't always show up the first time.
Are you a spouse or a vet?
I do see some women (old and young) at the VA...not sure of their marital/single status.
As a service vet you are allowed to ask for another provider that might be easier to communicate with.
There is the possibility it may have been service connected to begin with...throwing out maybeeees.
At each appointment the MD enters the info collected on to the computer re that days visit. The Govmt is a stickler on all info to be entered so any other MD in the system can read previous treatments etc.
On my visits I always ask the MD what the results were re my last visit or Blood work so I know where I'm standing on my needs.
It's a pain I know...stand in there...don't give up...Steve
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Old 01-14-2009, 02:08 PM
 
Location: Orlando, Florida
43,858 posts, read 41,327,695 times
Reputation: 58506
This looks like a good place to start:
http://tinyurl.com/7jzbop (broken link)

Quote:
request that a VA staff person verify your MHV account. Some veterans have two VA records; in this case, ask a VA staff person to merge the two records into one. Or, use the Contact Us link for Help Desk support.
Good luck to you!
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Old 01-14-2009, 02:10 PM
 
1,492 posts, read 6,434,158 times
Reputation: 1410
Thanks for the info. It would be no big deal....reject treatment could be just that - however, it has had an adverse effect on me- started upon checkout. So I know it will ripple thru the coming years when I seek treatment for my chronic back problems.

No overworked, underpaid doctor is gonna want to deal with a patient who rejects treatments.

So, spoke with a nurse in another state and she said DEFINITELY get it amended. So, I wrote a letter to the Release of Information section at the VAMC. I will follow up with them next week to make sure they got the letter and do amend it.

Steve, I am the Vet. And I've lived all over and can say with certainty that the NC VA healthcare system is the worst in the nation. Of course I haven't been to all VISNs, just 5 of them and there are what...9 or something?

Here they dismiss you mid sentence...that's probably what happened with primary care....so hurried to get me out of her office she didn't note the injections were not working. So when the new doc got my consult- he didn't know.
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Old 01-14-2009, 02:35 PM
 
Location: So. of Rosarito, Baja, Mexico
6,458 posts, read 16,604,482 times
Reputation: 5712
Next visit with the Primary Care...have a CANE and show difficulty walking due to excessive pain. Say the pain level is pushing 6-8 depending on whether your walking or sitting and is 24/7.

Took me 2 yrs to have surgery from them and of course "NO Guarantee" which is the norm. My surgery took care of 80% of my pain/numbness but still have same in the foot 24/7...use a cane and have a Handicap card for my car. May take over a yr to be fully healed from now (was 18 months initially).

Just complain and ask about pain pills. Certain pills act in limited cases. I have Hydrocodone 5/Acetaminophen 500MG TAB which does help for 4-6 hrs at night so I can sleep a little.

Hang in there...Steve

PS; San Diego has the best record for VETS healthcare in the US.
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Old 04-06-2009, 10:00 AM
 
1 posts, read 4,839 times
Reputation: 11
Default Correcting Records

VegasGrace, might want to look at this site and the posting on correcting records

[url=http://veteranclaimresearch.blogspot.com/2009/03/vets-correcting-records.html]Vet Claim Research: Vets & Correcting Records[/url]

For any Vets that need to amend or correct their records, this may be of interest:

Under 5 U.S.C. § 552a(d)(2), each agency that maintains a system of records within the scope of that statute must permit an individual “to request amendment of a record pertaining to him.” When such a request is received, the agency must either “make any correction of any portion [of the record] which the individual believes is not accurate, relevant, timely, or complete” or must inform the individual of the reasons for refusing to amend the record and the procedures for requesting review of that refusal.
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Old 05-05-2009, 08:38 AM
 
Location: Harrisonville
1,832 posts, read 1,935,107 times
Reputation: 398
Quote:
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.

How?
You have to go through the Privacy Officer anytime you want your medical record "amended", which this would be. They are the only people legally empowered to correct a mistake in the record. Calling in to the main number at the facility where you get your care and asking for the Privacy Officer should do it. This procedure is standard across the medical profession, not just military or VA. Good luck!
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Old 05-05-2009, 09:38 PM
 
48,526 posts, read 75,136,468 times
Reputation: 17823
You would likel;y get teh same response in a civilian setting. I have alot of friends whi had back problems and some the shots worked other it didn't. Some had other treatmentsthat worked for awhie. Others had thraopy that help because it strengthen the back muscles that took pressure off thei spine. Oher have lived with pain because the X-ray.MRI and such showed no clear therarpy that would ehlp eoither surgery or otherwise,.Most had actually refised treatment offered in many cases. Good luck
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