No Luck On Getting A Copy Of The Discharge Physical

[free_spirit_etc]

IRIS REQUEST:

My husband requested copies of his C-file last year, and made a limited request for a copy of his discharge physical - relying on information that he might be able to get a copy of his discharge physical quicker than he would be able to get the rest of the C-file.

I also requested both after his death.

I understand it takes quite some time to process these requests. However, I would like to see if a copy of his discharge physical can be located and sent to me as soon as possible.

I had an appointment at the VA Friday, July 2007 at 9 am to view my husband's C-file. I had assumed I would be able to at least see and read his dicharge physical on that appointment.

However, we could not locate the discharge physical in his C-file. The Service Medical Records didn't seem to be in any kind of chronological order. I couldn't figure out what kind of order they were in - but I made sure to leave them in the same order as they were in the file. But I looked all through the SMRs and was not able to locate the discharge physical. XXX also helped me look - but could not find it.

I know there was one in his file at some point because a couple of his C&P exam reports reference the discharge physical.

It was pretty disappointing not being able to even see the report that we have been requesting for a year, after driving a 10 hour round trip to do so.

As that was the only paper in the file I was specifically trying to locate, and we could not find it in the SMR's - could someone please locate my husband's discharge physical and send me a copy when they do?

Thank you,

XXX

IRIS RESPONSE:

Dear xxx:

At the time of your visit and review of the claims folder any and all information was in the c file at that time. We have no way of locating a discharge physical for your husband. If he did not submit a discharge physical to us at the time he initially applied for benefits we would not have this information.

You reviewed the entire folder. The document you speak of wasn't there. There is nothing else that we can do. We will send you an application that you may contact the military and they may still have a copy of his discharge physical. But no veteran is required to bring a copy of such or file a discharge physical with the VA upon their discharge from the military.

Thank you for using our website.

Sincerely yours,

xxxx

IRIS REQUEST

Thank you for your response to my inquiry.

My husband went to the base he retired from and got a copy of all of his post service medical records last year. They informed him that his discharge physical would be part of his Service Medical Records, which he had to request from the National Record Center. He submitted a request to the National Record Center last Spring and recieved a reply that they do not have the records as the records are in the possession of the VA. So he sent a request for a copy to the VA.

If the discharge physical is part of his Service Medical Records - and his Service Medical Records are in the possession of the VA, it has been somewhat difficult for him to submit the discharge physical to you, as he has been unable to get a copy of it from you.

The discharge physical must have been in his C-file at one point because a couple of the C&P exams make specific references to something that was said in his discharge physical. My husband recieved his post service medical care from the Military Treatment Center at xxx AFB, not from the VA. So it would seem that the only way the VA C&P physicians would have access to his discharge physical to discuss it in their exams would be if a copy of it would have been in his C-file.

And as the discharge physical is part of my husband's Service Medical Records - which are all supposed to be in the possession of the VA because the VA became the keeper of those records once my husband filed his VA claim, I fail to understand how it was my husband's responsibility to send his discharge physical to the VA in order for them to have it in his file.

I did not have time to go through the entire C-file at the time of my appointment.xxx, who assisted me in viewing the file, showed me where the discharge physical SHOULD have been located in his file. However,it was not in the file where it should have been. Again, the SMRS were not in any particular order in the file. They all appeared to be together, but they were not in any chronological order, some were upside down, some rightside up, etc. which made trying to find something take longer - and I only had one hour to view the file.

xx even checked his dental record file to see if his discharge physical had accidentally been put with them.

It is my understanding that the Separation Discharge Physical my husband recieved upon his retirement from the Air Force would have been part of his Service Medical Records.

It is my understanding that the VA has in its possession all my husband's official Service Medical Records, which means we are now unable to get them from another source as the Va has the original documents.

It is my belief that the VA C&P examiners would have had to have read his discharge physical in order to reference it in their reports.

I find the fact that my husband's discharge physical cannot be located, and nothing can be done about it pretty disturbing.

Thank you,

xxxx

Ms xxx:

We have responded to your inquiry. We have reviewed the claims folder. There is no other information at this time that we can give you. You have reveiwed the claims folder as you requested. The information you want was not there. There is nothing else we can tell you regarding the physical examination report that you want. We can send you a form as indicated and you can send off for the record from the military.

Thank you for using our website.

Sincerely yours,

xxxx

[Wings]

Bumping this, so I can respond in the AM. Tired and going to bed. The VA fails to amuse me, even worse are the bad dreams they give me! They do not have to give mental health patients their treatment records. .. 'night~wings

Even medical records - they have more records than those that are in your records. It seems like they have records and records...

One example - We went to the VA to get my husbands records. He was never treated at the VA - but he got his C&Ps there.

I was looking for his C&P for lung cancer. Didn't make sense. My husband kept swearing he NEVER HAD a C&P for lung cancer. But the SOC went on and on - "you told the examiner this. You told the examiner that.."

It was there. So I told him - you DID have a C&P for it. But then, looked - it is written on an EXAM form - LOOKS like an EXAM, but there was nothing on the report that was NOT in what my husband had WRITTEN to the VA - and it said the doctor was supposed to give an opinion after reviewing the record. That's all. They made it kind of sorta LOOK like an exam - but the doctor NEVER examined him.

Now surely they who have more forms than they know what to do with - could certainly come up with a FORM for a MEDICAL OPINION - so it would be CLEAR that it was NOT an exam.

The RO TOOK it as an exam (you told the doctor blahblahblah - NOPE - didn't SEE the guy).

Anyway - back to the point. When my husband ASKED - "Is this ALL my records?" A little bit of "well..uhmmm.." started. Well - uhm... there is a psychological exam..but we don't usually GIVE those to the patients - because it COULD upset them...

What???????????

Yes. People might get upset if they read their psychological exams..so they don't usually give them to them.

He asked for his.

They actually had to have someone come and READ it - and make sure there was nothing on it they thought might upset him before he was ALLOWED to have it.

I read more about that. It seems like psychological records CAN be kept FROM the patient under the guise of it being "for their own good."

I was even reading somewhere that with psych diagnosis they CAN make TWO SOC's - one REAL one - and one they give the vet (that doesn't mention some of the stuff that might "upset" them.

Well - how in the WORLD are you supposed to defend your claim - when they are giving you a DIFFERENT SOC than the one they are playing by.

I am not sure how often this happens. And your vet rep is supposed to get a REAL copy. But hey! How about providing a FREE ATTORNEY to everyone who has their psych records withheld from them - make sure their rigths are protected - if you take away their right to protect themselves <<<< my idea, not theirs...lol

AND - we went to the base to get his post service medical records..signed the papers ... got a stack. But it was just all those little computerized CLIFF NOTES type med records.

These are what the military and VA LIKE to use now. It is all computerized. Everyone can just pull it up on a screen. BUT it is mostly check off list kind of stuff.. with a scant bit of "notes.

I couldn't believe it. I said "Gee - you had a SURGERY - and it is reduced to A PARAGRAPH!! An ENTIRE surgery!! And all they have documented is ONE PARAGRAPH???

So he went out to the Base - and said - is his most endearing way - "What's this crap???"

LOLOLOLOLOL

They said - "Oh - we have OTHER records -- like doctors notes - these are just your MEDICAL records -- If you want your DOCTOR NOTES - we will have to get those from the DOCTORS.

Well..YEAH.. we really wanted them - because the doctor who had written about the asbestos exposure - who the base attorney said couldn't write us an opinion - told us to come and get HIS NOTES - and maybe they would help.

So - my point being - When you ask for ALL your medical records - you THINK you are getting ALL your medical records - but they can have all kinds of OTHER records that they don't CONSIDER your "medical records" (like doctor notes).

And here is another scary thing - when the VA requests your records - they most likely request your MEDICAL records - but that doesn't mean they will get doctor notes, etc. But the vet THINKS they got everything.

I think THEY should be responsible for KNOWING what is stored where - and getting it all.

Had we not been so shocked about the scant crap they gave us - we never would have known there were still other medical records that aren't considered your medical record. And most of our evidence is within THOSE records - NOT on their little Cliff Notes of Medical Care.

It just isn't right...

Free

[free_spirit_etc]

I was looking for some of the information - because I looked it up after the VA had to read my husband's psychological evaluation before deciding if he could have it. I thought that was horrid. But they were saying. "Well..they read it and get upset..." I thought - Well, YEAH..if you write a bunch of crap I bet they do.."

Anyway - I looked up some stuff because I thought it was a definate violation of patient rights, but apparently psych patients don't have the SAME rights as other patients.

Now I could see if someone was in there totally violent and beating on people and all. And maybe that is why they passed the law / regulation - whatever it is. But that gives the VA a lot of power to not give the reports to ANY patient, and act like they are acting in the person's best interest.

So there is no telling what they give you and what they keep just to themselves - all in the pretense of protecting you from knowing about yourself.

Geez... and then they wonder why people get paranoid..

I don't think it is just the VA - Not sure - there seems to be a different standard for psych patients and psych records...

Come to think of it - my husband was NOT a psych patient. He had ONE psych evaluation as part of his workup for the Fatigue C&P. And they still had to read the dang thing to see if he could have it.

Had it said anything they thought MIGHT upset him - they could have kept it from him.

And actually - had we NOT asked - Is this EVERYTHING?- we wouldn't have even known about it.

Anyway - Here is the reference for the SOC - on how the VA doesn't have to tell YOU every reason they deny you - if they can justify that they are "protecting" you from things you should not know.

It does not specifically mention psych claims - so it is even broader than that - but psych claims can certainly fall into this in a system where they have to read your psych eval before deciding if you can SEE it.

I remember I read this when Betty was having so many problems - and I kept asking her - are you SURE they are giving you the REAL SOC??? I thought maybe they were just giving her part of it - because so much wasn't making sense.

Here is the part from M-21-1MR

M21-1MR, Part I, Chapter 5, Section D

d. Matters Not to Be Disclosed in an SOC

Do not include matters in an SOC of a sensitive nature that would be injurious to the physical or mental health of the appellant, including

· matters considered by responsible medical authority to be injurious to the appellant’s health

· references to

· a prognosis of “poor” or “terminal,” or

· conditions of misconduct, unless the specific misconduct is relevant to the issue, or

· discussions of evidence in a way that might provoke feelings of hostility, resentment, or rejection on the part of the appellant or his/her family.

e. Disclosing Information to the Appellant’s Representative

All matters can be disclosed to the appellant’s designated representative unless disclosure to the representative would be as harmful as if made to the appellant. Therefore, in some cases, two different versions of the SOC may be prepared when it is permissible to furnish full information to the representative.

Use the table below when disclosing information to the appellant’s representative.

· If the appellant … has a representative And the … matters omitted from the appellant’s SOC may be released to his/her representative

Then … prepare a separate SOC for the appellant and omit matters not to be disclosed

· furnish copies of the edited SOC to both the representative and the appellant, and

· annotate the representative’s copy and the original SOC (full statement) to show what portions were deleted from the copy sent to the appellant.

Note: Annotate the statements to the effect that the material omitted from the appellant’s SOC is not to be revealed to him/her.

· If the appellant … has a representative And the …matters omitted from the appellant’s SOC may not be released to his/her representative, because the information might provoke feelings of hostility, resentment, or rejection on the part of the representative

Then … prepare a modified statement omitting these matters

· furnish copies of the edited SOC to the appellant and his/her representative, and

annotate the original SOC to show that matters not to be disclosed to the appellant or his/her representative were omitted from their copies.

· If the appellant does not have a representative And the …SOC contains matters not to be disclosed to the appellant Then … eliminate those specific references from the SOC that will be furnished to the appellant, and

annotate the original SOC (full statement) to show what portions were deleted from the copy sent to the appellant.

Edited June 14, 2008 by free_spirit_etc

[free_spirit_etc]

I found this -- about the Privacy Act and Psych Records - I can't really see how the VA can keep the psych reports from patients - except maybe in being a government agency - they might be exempt from the rules that apply to mere mortals

http://pn.psychiatryonline.org/cgi/content/full/43/8/24

Psychiatr News April 18, 2008

Volume 43, Number 8, page 24

© 2008 American Psychiatric Association

Psychiatric Practice & Managed Care

Do Patients Have Access to Therapy or Personal Notes?

Donna Vanderpool, M.B.A., J.D.

Donna Vanderpool, M.B.A., J.D., is the assistant vice president for risk management at PRMS Inc.

The HIPAA Privacy Rule and state law govern whether patients have access to psychotherapy notes. But understanding which one takes precedence and when is important to avoid falling into a legal morass.

The Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was created to provide standards for protecting the confidentiality of patients' individually identifiable health information. While the Privacy Rule gives patients a right to access their medical records, it permits psychiatrists who are covered by HIPAA to deny patients access to strictly defined psychotherapy notes. It's important to note, however, that under HIPAA psychiatrists are obligated to release these same notes to a third party if the patient requests that this be done. Moreover, laws in some states may allow patients firsthand access to those same psychotherapy notes, and such state laws continue to apply, notwithstanding HIPAA.

Many Fine Points to Consider

HIPAA's Privacy Rule permits covered psychiatrists who choose to keep psychotherapy notes to deny patients access to those notes. The Privacy Rule definition of psychotherapy notes is "notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's record."

The following information is considered part of the medical record and is excluded from the definition of psychotherapy notes: medication prescribing and monitoring; counseling session start and stop times; modalities and frequencies of treatment furnished; results of clinical tests; and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. According to the Department of Health and Human Services (HHS), the agency that enforces the Privacy Rule, psychotherapy notes are limited to information that psychiatrists keep separate for their own purpose and that contains sensitive information relevant to no one else. HHS equates psychotherapy notes with process notes.

It is important to keep in mind, however, that although the Privacy Rule allows psychiatrists to deny patients access to psychotherapy notes, it also states that patients may authorize the release of their psychotherapy notes to a third party such as an attorney, another provider, or even a friend, and that psychiatrists must comply with this authorization.

State laws differ regarding patient access to their medical records. In some states, patients have access to the entire record; other states prevent patients from accessing therapists' "personal notes" (or similar term). Additionally, some state laws may have other requirements for restrictions on the use and disclosure of these "personal notes."

The issue of which law to follow (state or federal) will ultimately be determined by the courts. Until this issue has been resolved, the following provides a starting point for analyzing questions about patient access to psychotherapy notes. Because this is a complex and developing area of the law, an attorney should be consulted for specific legal advice.

Patients may be entitled to access psychotherapy notes as defined by the Privacy Rule and/or personal notes (or similar term) as defined under state law

The legal concept of preemption basically means that the federal Privacy Rule preempts (trumps) a contrary state law and must be followed, unless the state law is "more stringent." More stringent state laws have been defined to include those that grant patients greater rights of access to the record. So, state laws granting greater rights of access to records (including psychotherapy notes, as defined by the Privacy Rule), will not be preempted and are to be followed.

In other words, if state law does not deny patients access to the notes, state law provides greater rights of access to the patient, and state law will apply. This is true even if a psychiatrist covered by HIPAA keeps separate psychotherapy notes that fit the Privacy Rule's definition, because patients have access to those notes under state law, regardless of the Privacy Rule's restrictions.

In contrast, if state law does deny or restrict patients from accessing personal notes, but those notes do not fit the Privacy Rule's definition of psychotherapy notes (that is, the notes are not kept separate from the rest of the medical record or the notes are kept separate but contain information relevant to other providers), then the Privacy Rule's provision requiring release of the entire record to the patient applies. That is, the exception under the Privacy Rule whereby patients may be denied access to their psychotherapy notes does not apply because the notes are not "psychotherapy notes" as defined by the Privacy Rule. State law restricting patients from accessing notes does not apply because the Privacy Rule's provisions provide greater rights of access for the patient. However, if the personal notes do fit the definition of psychotherapy notes under the Privacy Rule, then patient access to the notes can be denied, since the state and federal laws are consistent in terms of restricting patient access.

[Wings]

x

x

In this NPRC index, links to all subordinate documents removed and items have been sorted by NPRC number. Access to these subordinate documents depends on links internal to the documents themselves http://www.thememoryhole.org/nara/nprc/memo/Menu_EDITED.htm

Screening of military personnel and medical records for on-site review or for disclosure through photocopies

Screening required by the Department of Defense (DoD)

The DoD requires that NPRC screen military personnel and medical files to ensure that the following types of information are not released inappropriately:

a. Neuropsychiatric reports. These include:

(1) Diagnosis of a mental, psychoneurotic, or personality disorder.

(2) Diagnosis or implication of sexual deviation.

(3)

Any illness with a uniformly unfavorable prognosis

(such as cancer, a terminal illness, any illness leading to ultimate blindness).

See TITLE 32 (not 38)

Subpart A—DoD Policy

32 CFR 310.1 Reissuance.

This part consolidates into a single location (32 CFR part 310) Department of Defense (DoD) policies and procedures for implementing the Privacy Act of 1974, as amended (5 U.S.C. 552a) by authorizing the development, publication and maintenance of the DoD Privacy Program set forth by DoD Directive 5400.11

1

and 5400.11–R,

2

both entitled: "DoD Privacy Program."

1

Copies may be obtained at

http://www.dtic.mil/whs/directives.

32 CFR 3.10 PART 310—DOD PRIVACY PROGRAM

(f)

Access to medical records.

(1) Access to medical records is not only governed by the access provisions of this part but also by the access provisions of

DoD 6025.18–R.

(2) Medical records in a system of records shall be disclosed to the individual to whom they pertain, even if a minor,

but when it is believed that access to such records could have an adverse effect on the

mental or physical health

of the individual or may result in harm to a third party, the following special procedures apply.

(i) If a determination is made in consultation with a medical doctor that release of the medical information may be

harmful to the

mental

or physical

health

of the individual or to a third party, the Component shall:

(A) Send the record to a physician named by the individual; and

(B) In the transmittal letter to the physician explain why access by the individual without proper professional supervision could be harmful (unless it is obvious from the record).

(ii) The Component shall not require the physician to request the records for the individual.

(3) If the individual refuses or fails to designate a physician, the record shall not be provided. Such refusal of access is not considered a denial under the Privacy Act (see paragraph (a) of §310.18).

(4) If records are provided the designated physician, but the physician declines or refuses to provide the records to the individual, the DoD Component is under an affirmative duty to take action to deliver the records to the individual by whatever means deemed appropriate. Such action should be taken expeditiously especially if there has been a significant delay between the time the records were furnished the physician and the decision by the physician not to release the records.

(2) The personal uncirculated handwritten notes of unit leaders, office supervisors, or military supervisory personnel concerning subordinates are not systems of records within the meaning of this part.

Such notes are an extension of the individual's memory.

These notes, however, must be maintained and discarded at the discretion of the individual supervisor and not circulated to others. Any established requirement to maintain such notes (such as, written or oral directives, regulations, or command policy) may transform these notes into "Agency records" and they then must be made a part of a system of records. If the notes are circulated, they must be made a part of a system of records.

Any action that gives personal notes the appearance of official Agency records is prohibited, unless the notes have been incorporated into a system of records.

(i)

Relationship between the Privacy Act (5 U.S.C. 552a) and the FOIA (5 U.S.C. 552).

Not all requesters are knowledgeable of the appropriate statutory authority to cite when requesting records.

(ii) Requesters who seek records about themselves contained in a Privacy Act system of records,

and who cite or imply only the Privacy Act

, will have their records processed under the provisions of this part and the FOIA (32 CFR part 286). If the system of records is exempt from the access provisions of this part, and if the records, or any portion thereof, are exempt under the FOIA, the requester shall be advised and informed of the appropriate Privacy and FOIA exemption.

Only if the records can be denied under both statutes may the Department withhold the records from the individual. Appeals shall be processed under both Acts.

(iii) Requesters who seek records about themselves that are not contained in a Privacy Act system of records, and who cite or imply only the Privacy Act, will have their requests processed under the provisions of the FOIA (32 CFR part 286), because the access provisions of this part do not apply. Appeals shall be processed under the FOIA.

(iv) Requesters who seek records about themselves that are contained in a Privacy Act system of records, and who cite or imply the FOIA or both Acts, will have their requests processed under the provisions of this part and the FOIA (32 CFR part 286). If the system of records is exempt from the access provisions of this part, and if the records, or any portion thereof, are exempt under the FOIA, the requester shall be advised and informed of the appropriate Privacy and FOIA exemption. Appeals shall be processed under both Acts.

(v) Requesters who seek records about themselves that are not contained in a Privacy Act system of records, and who cite or imply the Privacy Act and FOIA, will have their requests processed under the FOIA (32 CFR part 286), because the access provisions of this part do not apply. Appeals shall be processed under the FOIA.

(2) Do not deny individuals' access to personal information concerning themselves that would otherwise be releasable to them under either Act solely because they fail to cite or imply either Act or cite the wrong Act or part.

32 CFR 310.18 Denial of individual access.

32 CFR 310.19 Amendment of records.

Edited June 14, 2008 by Wings

[71M10]

Greetings all:

I have a bit of a theory on discharge physicals. When I left the service in 1988 they gave me two sets of chest x-rays and sent me to an additional doctor to clear me for discharge. Fast forward to 2007, VA says they do not have my discharge physical and the smr's they sent me seem to be complete except for the discharge physical that is missing. When I requested a complete copy of SMR's from St. Louis I recieved a copy of a document indicating that Detroit VARO signed for my smr's and discharge physical direct from Fort Bliss Texas (filed for back on discharge in 1988). I suspect that the US Army identified I had an enlarged heart at that time, discharged me, and 86ed the physical. They sent the smr's to VA and indicated the separation physical was included. I doubt that VA inventories or ever inventoried the contents of files transferred to them. The Army hides the fact they separated someone for non-medical reasons when they identified a serious medical condition, and when someone squaks about the missing physical they have "evidence" that it was sent to another agency.

VA is so disorganized and loses so much other stuff that they make the perfect scapegoat. I am trying to find out if the transition point is required to keep medical records of exams they conduct? I am trying to get copies of the x-rays (should be part of the facilities files).

Yes I am getting paranoid, and would like to remind people that the best conspiracies are never detected or identified.

Best regards,

Tyler

[Wings]

Greetings all:

I have a bit of a theory on discharge physicals. When I left the service in 1988 they gave me two sets of chest x-rays and sent me to an additional doctor to clear me for discharge. Fast forward to 2007, VA says they do not have my discharge physical and the smr's they sent me seem to be complete except for the discharge physical that is missing.

When I requested a complete copy of SMR's from St. Louis, I recieved a copy of a document indicating that Detroit VARO signed for my smr's and discharge physical direct from Fort Bliss Texas (filed for back on discharge in 1988).

I suspect that the US Army identified I had an enlarged heart at that time, discharged me, and 86ed the physical. They sent the smr's to VA and indicated the separation physical was included.

I doubt that VA inventories or ever inventoried the contents of files transferred to them. The Army hides the fact they separated someone for non-medical reasons when they identified a serious medical condition, and when someone squaks about the missing physical they have "evidence" that it was sent to another agency.

VA is so disorganized and loses so much other stuff that they make the perfect scapegoat. I am trying to find out if the transition point is required to keep medical records of exams they conduct? I am trying to get copies of the x-rays (should be part of the facilities files).

Yes I am getting paranoid, and would like to remind people that the best conspiracies are never detected or identified.

Best regards,

Tyler

Tyler, After dealing with those Departments, being paranoid or suspicious becomes a natural instinct! I use my paranoia sniff out information or facts! What I',m learning this week, is that a lot of inner offices and agnecies of the military departments have different storage and time retention regulations.

If that Discharge Physical does not go directly to St Louis, then it can get lost by the wayside. You say you filed a VA Claim prior to discharge, if that "enlarged heart" was duly noted, then somebody had to manually process those records. Does your DD--214 indicate that you elected (checked the box) for sending DD-214 to the VA?

In the near future, I'm afraid it will be rare to have a hard-copy of any medical records. It will become increasingly difficult to challenge or correct administrative records. All those millions of dollars spent on new computer technology, yet mistakes are made every day --and we all know HOW LONG IT TAKES to correct a government error.

I am studying induction and discharge physicals. I'll keep posting if I find something. Check out this Chapter 4 (linked below). I wish I understood all the acronyms, but I do not. ~Wings

http://www.vetsforjustice.com/Claims%20Records.htm