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Falsification Of Medical Record Vamc West Haven

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i was a former member of this forum as hotcoffee1. I have lost the negligence claims through via ftca, and the statute of limitations passed. I was too unwell to pursue the case per se in connecticut and could not obtain legal representation. I was ultimately diagnosed June 2008 with dystonia of the posterior tibialis and I am receiving botox shots to assist with ambulation. I am awaiting decision 1151.

There were two criminal misdeeds during my treatment. these were the falsification of a clinical note titled preoperative exam. During this exam the informed consent discussion although documented was never held. the physical exam notes were cloned, and this was medically contraindicated as my opposing leg has a congenital defect. as there are criminal issues involved in my treatment, i have logged a complaint with the VAOIG. I have been told by the OIG (there has been no formal dispostion of the case as the OIG has 30-60 days to respond or not respond as is their directive). So here are the emails. judge for yourself:


In a message dated 9/29/2008 9:35:16 P.M. Eastern Daylight Time, writes:

1.) a clinic appointment in my medical record was falsified by the VAMC West Haven DPM on April 14,

2005. I was not present for an appointment scheduled that date (there is none listed on appointment listing) and I have a receipt for a purchase i made at the date and time the record was created. The clinical note was for a H and P exam and the informed consent discussion. nonesuch activities occurred and the note is not compatible with standards outlined in the health record review practice.
2) i discovered the vha compliance group via internet. i contacted them august 6-7 2008 via the 866 number.case xxxxx-xx. to my utter and total dismay, the local compliance officer, Mr. Jack Bruce informed me there was another note in the system that indicates that the falsified note was valid. this second note cannot be read by VAMC Togus, nor has it ever been given to me in a request for records. per mr. bruce this record resides in VAMC West Haven CPRS. The note was faxed to marjorie poulin privacy office vamc togus. a copy was given to me. mr bruce and his supervisor jane kiljemmy (phonetically spelled) Network 1 Compliance, claimed that the note is an
of a clinical visit i had on April 11, 2005. The April 11, 2005 note is inconsistent with the business practices of the VHA, It does not delineate the second note as an addendum 2) there is no reference to it being an extension of the April 11th note 3) it does not have a proper header, it appears to be a copy and paste job. i.e. it is titled H and P, it has the date of April 14, 2005 and the header is also carries the date of April 11; the note has the EXACT DATE and TIME of the April 14th note AND the signature block is not left justified but is situated in the middle of the note (appears to be cut and pasted) the signature block is the EXACT SAME AUTHORS AND TIME STAMP of the 14th note. My question is, what VISTA/CPRS utility or routine (computer) would allow a person to write two notes at the same date and time? I believe the April 11th date was also copied into this second note. that duplicate date and times do not allow the note to be uploaded to VISTA web. This is why I have never received a copy of this note in my medical records. It is also absent in records copied by the Regional Counsel and Office of General Counsel sent to me per my written request. 3) i torted my case for negligence with the regional office and office of general counsel. I have been repeatedly told that VAOIG cannot look into this criminal matter. My last call the hotline person told me to accept the findings of the VAMC West Haven....... my torts were negligence this is the criminal aspect of the case. 4) The physical exam clinical notes preop are cloned. the notes do not reflect the proper exam of an unstable ankle and a subluxed tendon. my opposing leg had a significant congenital defect 5) An outside practioner DPM was to be the attending for the case. I was purportedly (NOT) advised during any clinical visit whether it was held on the 14th or the 11th. As I understand the requirements for a contractor, he was supposed to be familiar with the surgery to be performed (as determined by the VAMC West Haven Chief of Staff); perform an examination of me (he did not). Add comments to the preop note, and discharge summary and sign the operative note. (the operative note went unsigned for six weeks and under those circumstances was to be signed by the chief of staff). this contractor (or is he an employee of VHA?) indicates in my record that the case is finished and i am in the PACU. From PACU and handwritten anesthesiology records, I am in surgery for another half hour. The Chief Resident notes the attending was present for all critical aspects of surgery.......which brings me to item number 6 6) There is no way to fully determine who assisted the attending during surgery. a resident other than the one that wrote the preop, operative, and discharge summary is identified as the first assistant. the first assistant is another resident per the nursing operative note. anesthesia identifies another individual as the prime resident for the case. West Haven FOIA and PO officers REFUSE to provide me with the name of the resident assisting the attending. Mr. Gaudio (presently VISN1 priviacy officer) was PO at the time. He said he would provide me with the names of the residents in the operating room. This does not address my request for the name and qualifications of resident assisting the attending. 7) I have not received a copy of the compliance study. I can tell you that interpretations of the vha handbooks, standards set for supervising residents, cloning of notes in lieu of a proper physical exam (the PE notes document I am unsteady, when in fact I am simply limping, a product of my congenital hip); addending clinical notes, standards set for documenting the informed consent discusion, were not observed. compliance indicates that because i signed the informed consent document i have been properly informed. the informed consent document describes elements of the surgical procedure that are not documented in my notes...specifically i am referring to "tendon transfer" as a surgical option on the consent form. it does not delineate what tendons are to be transferred. i also do not believe the chief resident who was present when i signed the form had any experience whatsoever in the surgeries she was to have informed me of. Hopefully this is enough for you guys. I hope this gets past the hotline for godssake. this is just a basic outline of what the issues are. I have this case moving at the 1151 level, I have retained Dr. Bash as a medical expert to examine the care I received by the DPM VAMC West Haven. I can be reached at 207-xxx-xxxx I would like a response if you are NOT examining this case further. patti k.

Addendum #1 On September 29, 2008, I spoke to two groups of people. The first was the VISN 1 FOIA/PO, Dale Guadio, who insisted that the computer system at the time "forced the user to start a second separate note", in my case date April 14th, 2005. So observance of the business rules to addend the April 11th, 2005 note was (by implication) not in effect. He also claimed via the phone call that "nobody remembers the facts of the case in 2005". The point I continue to make is the note of April 11th should stand as written and the note(s) of April 14th are falsified. This is a criminal act in accordance with VHA Handbook 1907.1. The second conversation occurred with the OIG call screener (elizabeth?) for the afternoon of September29th, 2008. This woman told me that even though a federal law had been broken, the US attorney (in this case Connecticut) would not take the case because the damages were "minimal". The fact that the informed consent was never discussed with me and the form I signed had a surgical alternative ("tendon transfer") without specificity on the consent form itself or within the medical record, would not constitute a case that the US attorney would take for prosecution is unacceptable. You have withheld this case because I had complained that the contracter (Dr. Saracco) had falsified records and did not perform his contractual duties is no reason is unacceptable. The professionals at the VAMC West Haven have essentially taught the resident staff to lie on record.......you cannot find the wherewithall to act on this matter? message dated 9/17/2008 1:26:29 P.M. Eastern Daylight Time, writes:

Addenda #2 My negligence case with the OGC (Atty. Joan Weber) was also compromised by these falsified notes (the April 14, 2005 and the note that resides in CPRS and must be specially invoked. My OGC case was twofold. the first aspect of it was negligence, and the second aspect of the case dealt with falsification of medical record and lack of informed consent. Ms. Weber, according to the documents I received, never received a copy of the note that resides exclusively in CPRS. Her investigation into this matter would have been shortchanged

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Patti, Top Notch law firm, in Austin Tx. Archuleta,Alsaffar,Higginbotham.(google them)Peace, William

P.S. I grew up in South Windsor,Ct. moved too Florida in 2003

Edited by william n
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