Doctors/nurses/others Hand Written Notes

[betrayed]

A thought occured to me as I was reading my SSOC and SOC's, C&P Examiners make hand written notes when they do examinations. Has anyone ever requested hand written notes through the records office?

The reason I am asking this is I am planning my fight to establish a earlier effective date on one of my conditions. I remember a C&P examiner stating something to me during a exam, this was also stated in front of my wife who was present at the exam.

The doctor told me (at my very 1st C&P) that she thought I suffered from depression. There is no mention of it in the report. I was wondering if she could of possibly wrote that down in a hand written note?

I am going to fill out a records request for hand written notes made by the examiner during the exam and see what I get back.................

[Former Member]

Documentation of Nurses notes helped me succeed in my wrongful death claim.

My c file copy revealed other notations etc- some were quite bizarre----

I had a fight with a VA SOC opining doctor many years ago-

we made up -after I knocked down 2 of his Expert medical opinions in the late 1990s.

I called him last year-

what astonished me was that as we talked he pulled out his actual notes on the opinions he had rendered for those SOCs.

He said he also found out that the VA did not give him the proper evidence when he opined on the claim.

He offered complete support for my new AO claim-

one more doctor agreeing with the evidence-

but because I knocked his other stuff down- he could not render anything for me at all regarding the newer claim.

I never asked for a copy of his handwritten notes-he had re-typed them too and part of them were used in the SOC.

You could ask for a copy from your former C & P doctor.

Then again maybe they were never documented at all.

[betrayed]

Then again maybe they were never documented at all.

I saw her writing them down on paper

[Guest jangrin]

A thought occured to me as I was reading my SSOC and SOC's, C&P Examiners make hand written notes when they do examinations. Has anyone ever requested hand written notes through the records office?

The reason I am asking this is I am planning my fight to establish a earlier effective date on one of my conditions. I remember a C&P examiner stating something to me during a exam, this was also stated in front of my wife who was present at the exam.

The doctor told me (at my very 1st C&P) that she thought I suffered from depression. There is no mention of it in the report. I was wondering if she could of possibly wrote that down in a hand written note?

I am going to fill out a records request for hand written notes made by the examiner during the exam and see what I get back.................

This is just an idea....

Betrayed, usually doctor's notes are not included with the records when someone requests patient records. However, when patient records are requested by a subpoena the request will ask for any and all records including, films, notes, archived, any type of media records and then the person gathering the records has to sign that they have included everything.You might be able to get the actual "notes" through a FOIA request specific to the doctor rather than just the VA. I think the standard for keeping ALL patient records is

7 years before they can be destroyed.-jangrin

Edited May 5, 2007 by jangrin (see edit history)

[LarryJ]

Or, it could be like my last visit with my primary care physician.

My wife, an RN, had written down my medical history, going all the way back to when I broke my wrist playing football in 1962. She had covered EVERYthing, up to and including the fact that I take one baby aspirin, etc.

He just takes the stuff that she had written down and dictates all of it into the computerized medical records right then and there.....I take the notes from my wife and bring them back home with me after my visit. No handwritten notes will exist for this visit.

And, of course, many doctor's notes are processed in exactly the same way, they are dictated directly into the medical records, either thru the computerized system as my doctor did, or via voice recordings that will later be transcribed by the medical records transcriptionists. And, if the doctor DID write down something during your visit or treatment, it was most likely dictated into the medrecs the same way, and then pitched into the trash can before the doc went home that day.

Hence, no hand-written notes.

[free_spirit_etc]

I still think it would be a good idea to ask for them. (I just posted on this in the Retiring soon thread).

When my husband requested the Doctor's RECORDS -- we even got actual INTAKE reports -- long - typed - etc - that were NOT included in his "medical records" when he asked for those.

So I would ask for any and all records that anyone has -- and keep asking what other records to ASK for...

I would also think that an argument could be made that any of these records be considered part of the file - whether they were in the file or not. If the VA KNOWS the records exist -- and say they HAVE the records -- then the vet should be able to assume they HAD them.

We assumed the VA HAD the doctors reports from post service base medical records. Whether they had them or not - I don't know... I haven't seen the C-file yet.

But - hey! When the VA states they have your post treatment records from the base -- you SHOULD be able to assume they have them ALL -- especially when the VA should know they have other records than just the "medical file." So if they didn't have them ALL - that should be able to be an argument that the facts, as they were known at the time, were not available to the adjudicator when he/she made a decision.

Unless the VA expects the veteran to know that when the VA says they have your records they really don't have them ALL - and you are supposed to TELL them to get doctor's notes.

Free

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