Can I Amend Clinic Medical Notes About Me?

[cowgirl]

Cowgirl question of the day. I need to clear up errors in my VA medical records. What is the procedure to amend or add notes to clarify medical notes? Is there a VA form to use? For example, a doctor put incorrect marriage information in their notes. A different doctor added notes about a 'self reported' diagnosis of a condition that I am not diagnosed for.

Thanks for the help, I may have asked this question before, forgive me.

Cg'up2009!

Edited April 22, 2009 by cowgirl

[Pete53]

It is not easy. You have to get copies and show what is wrong than the person who did it has to agree. At least that is what I was told when I wanted erroneous default answers to questions I was never give in my medical records.

[sharon]

For any Vets that need to amend or correct their records, this may be of interest:

Under 5 U.S.C. § 552a

d) Access to Records. - Each agency that maintains a system of

records shall -

(1) upon request by any individual to gain access to his record

or to any information pertaining to him which is contained in the

system, permit him and upon his request, a person of his own

choosing to accompany him, to review the record and have a copy

made of all or any portion thereof in a form comprehensible to

him, except that the agency may require the individual to furnish

a written statement authorizing discussion of that individual's

record in the accompanying person's presence;

(2) permit the individual to request amendment of a record

pertaining to him and -

(A) not later than 10 days (excluding Saturdays, Sundays, and

legal public holidays) after the date of receipt of such

request, acknowledge in writing such receipt; and

(B) promptly, either -

(i) make any correction of any portion thereof which the

individual believes is not accurate, relevant, timely, or

complete; or

(ii) inform the individual of its refusal to amend the

record in accordance with his request, the reason for the

refusal, the procedures established by the agency for the

individual to request a review of that refusal by the head of

the agency or an officer designated by the head of the

agency, and the name and business address of that official;

(3) permit the individual who disagrees with the refusal of the

agency to amend his record to request a review of such refusal,

and not later than 30 days (excluding Saturdays, Sundays, and

legal public holidays) from the date on which the individual

requests such review, complete such review and make a final

determination unless, for good cause shown, the head of the

agency extends such 30-day period; and if, after his review, the

reviewing official also refuses to amend the record in accordance

with the request, permit the individual to file with the agency a

concise statement setting forth the reasons for his disagreement

with the refusal of the agency, and notify the individual of the

provisions for judicial review of the reviewing official's

determination under subsection (g)(1)(A) of this section;

(4) in any disclosure, containing information about which the

individual has filed a statement of disagreement, occurring after

the filing of the statement under paragraph (3) of this

subsection, clearly note any portion of the record which is

disputed and provide copies of the statement and, if the agency

deems it appropriate, copies of a concise statement of the

reasons of the agency for not making the amendments requested, to

persons or other agencies to whom the disputed record has been

disclosed; and

(5) nothing in this section shall allow an individual access to

any information compiled in reasonable anticipation of a civil

action or proceeding.

[cowgirl]

Thanks Sharon, you are stalwart veterans advocate and a storehouse of knowledge. Timely too!

Cg'up2009!