tdiu Unsigned Medical Report

[Charleese]

Hi all,

As you know my husband's friend was denied TDIU, cervical myelopathy and low back condition which was secondary to his right knee injury. I posted here several days ago under TDIU Denied if you care to get a background of TDIU. However, in VA's decision they used a Doctor's Progressive Notes which was never signed by a doctor nor states doctor's name on note to deny him service condition on a secondary basis. The note states in part: ".......These records document your reports as to the circumstances of your fall, to include stepping from your car and missing a step and falling, falling while making a delivery on the job, and falling after getting out of your ar, however, there is no indication that you reported that your fall was related to your service connected right lower extremity disability." It goes on to further state: The evidence does not show that residuals of cervical myclopathy, Brown-Sequard Syndrome, with quadriparesis, status post anterior discectomy, fusion, and plating at C3-C4 is related to the service-connected condition of residuals of fracture right tibial tubercle with osteoarthritic changes and chronic chondromalacia of the knee. Therefore, service connection, on a secondary basis is not established. Furthermore, as there is no evidence of this diability during military service, service connection, on a direct basis, is also denied.

As you know he has a signed Hospital Consultation Request signed by Hospital Nureo Surgeon stating that he fell because of his right knee service connected injury,which VA conviently failed to use. Consultation Request was done on o8/5/08 and Progress Note was done 8/15/08. Vet denies emphatically telling anyone "that he missed a step and fell."

My question is do anyone know whether VA can use an unsigned Medical Report without doctor' name on it as evidence to deny a claim. If there is a regulation on this please post.

Thanks in advance for your replies.

[Philip Rogers]

Someone just recently posted something on unsigned reports. I think it was deltaj but not sure.

pr

[carlie]

http://www.hadit.com/forums/index.php?show...mp;#entry193376

[jbasser]

According to the denial there is no nexus connectiong the 2 conditions together. That is is what is needed.

J

[Charleese]

jbasser. there is a nexsus. Vet's Primary Doctor wrote one and rater is saying that providers statements/nexus was purely speculative because they were not at the scene of accident, nor involved in the medical care rendered subsequent to this event. This is not true and his Primary Doctor intends to issue another IMO as well as refute this for him.

Carlie, I looked at this and I don't quite understand what it is actually saying. Does this apply to this vet's case and are they saying that VA can use an unsigned document. Please help me to understand.

Thanks!

[carlie]

Carlie, I looked at this and I don't quite understand what it is actually saying. Does this apply to this vet's case and are they saying that VA can use an unsigned document. Please help me to understand.

Thanks!

Charleeese,

I feel the VA medical records will contain virtual signatures

and if not VA will manufacture the virtual signature.

[vperl]

Charleeese,

I feel the VA medical records will contain virtual signatures

and if not VA will manufacture the virtual signature.

************************8

How cynical can you be, but then again you are totally correct 100%

(how many bolts of "whole cloth " does the VA have on hand ?)

Edited March 17, 2010 by vperl