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Pre-programmed “false Statements” On Veterans’ Va “medical Record Progress Notes”

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  • Elder




“PRE-PROGRAMMED FALSE STATEMENTS” on Veterans computerized “Medical Record Progress Notes” that are intentionally or unintentionally not corrected to describe the Veteran-patient’s true medical condition or its “residuals,” are or could be used as a “bases to deny” Veterans’ service-connected and non-service connected disability claims, federal tort claims, and social security disability insurance claims, among other things.




Below are samples of “Pre-Programmed” statements that you will find on your “Medical Record Progress Notes” that may or may not be accurate. The ones highlighted, if not accurate, are the ones most likely to cause your claims to be “denied.”

So after reading the information below, whether you have a pending VA or other Government Disability claim or not, be sure to check all of your current and future VA medical records for accuracy… You can get a copy of any of your VA medical records from the “Release of Information” Office at the VA Medical Center where you receive treatment.

• This patient denies any other new medical problems.

• “The patient ‘DENIES’ both short-term and long term exercise intolerances.

• “The patient ‘DENIES’ profound muscle weakness, which unable him to raise his arm to comb hair, stand up from a chair or lift his head from a pillow, fascial rash, Gottron sign, v-sign, and shwal sign.”

• “The patient ‘DENIES’ LE claudication and foot drop.

• “The patient ‘DENIES’ symmetric polyarticular arthralgia/arthritis, malar rash, oral ulcer, discoid lesion, photosensitivity, nephritis, serositis, dry eyes and dry mouth, Raynaud’s phenomenon and sclerodactyly.

• There has been no persistent nausea, emesis, or diarrhea, no persistent fever or chills, no acute sino-bronchitic symptoms, no acute dyspnea, no hemoptsis, no recurrent GI or GU bleeding, no significant chest pain or unstable anginal episodes of concern to the patient, no persistent weight loss, no UTI symptoms, no synscope, no TIA episodes, no persistent irregular bowel movements, no persistent anorexia, and no unusual palpitations.

• The tests were reviewed with the patient.

• Otherwise the patient has no further medical complaints.

• Also the patient relays no new significant signs of symptoms referable to the ENT, Constitutional, pulmonary, cv, GI/GU or Neurological areas occurring since the last clinic visit.

Also Visit the following other Pre-Programmed Categories on your

VA “Medical Record Progress Notes” and check them for accuracy:

• Vital Signs, Reason for Visit, Pain Score, Allergies, Active Problems, Active Medications, Selected Medical History, Chief Complaint, History of Present Illness, Exam, Assessment, Mental Health Status, General appearance, Head/Neck, Eyes, Ears/Nose, Mouth, Chest/Breast, Lungs, Cardiac, Abdomen, Genitalia/Hernia, Rectal/Prostate, Back, Feet, Extremities, Skin, Lymphatics, Neurological/Psychiatric, Mobility, Activity Intolerance, Activity of daily living, Nutrition, Evidence of abuse or neglect, potential barriers, tobacco use, exercise, Contraindication to vigorous exercise, alcohol screening, PTSD Screen, PTSD Score, Mood Screen, Mood Score, Colorectal Screening, Vaccinations, Sun Protection, Hypertension, COPD, Diabetic Foot Examination, Plan, Active Medications.





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I think you posted something about this earlier, or maybe it was someone else, but......... it significant and SOMETHING needs to happen about it. There is also a VA "back-channel" message system that the veteran never sees, and to my kowlege cannot get a copy of. Its solely among the medical VAMC's though, not on the raters system.

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  • Elder

Hello Bob,

It will be interesting to see how the court views these records.

The VA, US Justice, etc. should be able to use undercover agents to investigate & prosecute NSO's, VA claims adjusters, contract adjusters, C&P examiners & VAMC health care staff, for fraudulent & unethical practices.

Once they do the stake outs for six months or so, with out anyone being aware of it, they will end up saving the tax payers a load in retirement benefits for crooked federal employees. Who knows? Maybe they've been investigating for six months already & they're about to make the sting.

Wishful thinking?


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  • Elder

Are they saying that if a Veteran denies a condition that they consider it a false statement? This is very perplexing.

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  • Elder

Hello Pete,

whats fraud to me is,

when my provider wrote in my progress notes, that I "refused" long acting pain medication, than he refused to prescribe any pain meds for nearly six months.

When another wrote, (after reviewing a great deal of smr's & information from the DOD website), concerning project shad & the USS Twining; the only thing my service meedical records,(SMR"s) showed I had wrong with me was jock itch.

wHen the VARO stated they never recieved a favorable VAMC C&P examination & medical opinion, than denied the claim after getting what they wanted from a contract consultant.

Also had a comment show up in one C&P examiners remarks, that really pissed me off. They denied my NSC pension claim over it. He supposedly remarked that he smelled alchohol on me & my clothing at this, 8am C&P examination, 150 miles from home, with two children & my wife in a 62 chevy 3/4 ton truck on icy roads.

The examination was for "neuromuscular disorder of unknown cause"-probably multtiple sclerosis.

They must have thought it was a good way to explain why & slurred my words, staggered & had vertigo. Didn't work, but they tried anyway.

the list goes on & on..........

Edited by allan (see edit history)
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  • Elder


I slurred my words, staggered and had mild dizzyness for a year and a half. For the first three months the doctors at the VA told me they had no idea what was causing it. Eventually, I saw a VA doctor who told me all the doctors who had been treating me were absolutely under-diagnosing my problem and failed to schedule the proper tests to determine the cause of the symptoms. She was really pissed that I had been to neurology and they did not do an MRI on my neck. She called a PA into the office and told her to go with me to the neruology clinic and make sure they did not weasle out of scheduling the MRI on my neck. After taking a comprehensive history and getting the MRI results she attributed all the symptoms to cervical degenerative disc disease.

If you look at the literature you will find that herniated cervical discs can cause all of the symptoms you listed. It is all medical politics if you ask me. The doctors who are on the side of the patient will schedule the tests and make the diagnoses. The doctors who are trying to save the Govt. some money play dumb and do not schedule tests.

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Interesting Info----

and this is why every vet should pour over their med recs-

I used to support my AO death claim-various VA med recs that showed VA was close to diagnosis of Diabetes in my husband- but failed to diagnose it at all.

The sole VA doctor who wanted to diagnose diabetes was overruled-

Twelve years later (It took time to find him in private practice now on the west coast)-he gave me a brief IMO that Dr. Bash incorporated into his main IMO.

Another doctor in the med recs had written the symbol for an arrow pointing left and then DVD-upon Rods admission to the SYracuse VA.

They had not seen his med recs yet- and they assumed that anyone with a catastrophic stroke like his, must have had diabetes as the probable cause-

I used LexisMedicon and Merck-2 publications that VA uses also-

to find out that the symbols meant -history of Diabetic Vascular Disease.

A VA expert doctor tried to say that I was wrong and that the symbols meant the patient "Denied Venereal Disease"

yeah right-

I rebutted with the actual printouts from Lexis medicon and Merck and stated that

these are the same medical dictionarys that caused me to win my FTCA wrongful claim.

In 1988 a med cert said RO/CAD-

I didnt know what that meant as they had treated the veteran with sudafed when he collapsed while at work at the VA one day.

EKG results the same day -hard to interpret-until I got some cardio medical books-revealed that Rod had an abnormal cardiac event- then another entry stated WU for CAD.Also it took me quite some time to understand an entry at to diaporetic.

Long story-but

I won wrongful death claim based on these records that fully supported the veteran had been misdiagnosed, had a heart attack that day, received counterproductive meds (sudafed) and the VA had failed to WU -work up- and then RO rule out CAD-cardiovascular disease.

VA doctors attempted for 3 years to deny the Sec 1151 claim that was filed with the FTCA- by trying to say what the med recs said was NOT what they really said-

It certainly pays to read and read and then read again what you med recs have in them-for any disability----

because what you need might be in them but if the VA is interpreting it all to go against the claim ---- they might be quite wrong.

In those days I had to obtain medical texts myself-these days the internet has made this info mere clicks away-

The most obscure symbol or entry in your med records can have a potential benefit to your claim.

Of course a good IMO doctor finds all that- but vets can do by fully reading their med recs and looking up whatever they dont understand-

or even asking the VA doctor.

I was able to get an entire entry page typed from handwritten notes that were completly illegible-by a VA doctor.

The results on that were very alarming.

Edited by Berta (see edit history)
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