What Form Do I Use To Make Corrections To Medical Records?

[allan]

Does anyone know what form to use and how to make corrections to your VAMC medical records?

Edited June 25, 2010 by allan

[Katee]

1.  According to the VA, you should send a letter "...stating explicitly what information is in contention and why, i.e.  inaccurate or erroneous, irrelevant, or incomplete."   In plain language tell the VA what they got wrong. 

2.  If possible, include with your letter a printed copy of the doctor's note and circle or highlight the sentence, paragraph, or aspect of the record that is not correct.

3.  Include in your letter:

  a. Your name, including your middle name

  b. Your date if birth

  c.  Your Social Security number and the

   d.  Date you are writing the letter

4.  If for some reason you cannot include arinted copy of the medical record, be as specific as possible  describing the specific medical record with the mistake such as:  date of the medical record, time of day, name of the clinic or service, doctor or clinic Ian's full name, type of visit..

5. Sign your letter in ink.

6. Address your letter to the PRIVACY OFFICER at the VA Medical Center or main facility VMAC.

[Berta]

Good question-I never heard of any form at all for this.

I wanted something entered into my husband's medical records. It took getting an appointment with the Chief Medical Director to do it.

They also called the VA cops when I showed up.The cops left when I asked if I could make a phone call to the Corning Newspaper or to my Congressman.I gave them the choice of who wold get the phone call and I pulled out a dime.

Obviously I need to leave out the whole story here.

The Chief Medical Director's entry was part of my probative evidence for my wrongful death case.

If you mean corrections to typos or are having problems understanding the old handwritten clinical entries, I had that problem too and the VA got a transcriber to meet with the doctor and type the doctor's entries in a legible fashion...That too became probative evidence for my case.

Other than that- if this is a diagnostic error I wold contact the Director of the VAMC that you deal with.

My husband's records were full of medical errors Allan.If their medical errors are documented and have caused you additional disability-you have good cause to file Section 1151 claim and/or FTCA claim.

If it is a case of disagreement with their diagnosis and treatment, then it is time to get an independent doctor.

If these are corrections that arose from statements in a SOC, then they can become part of the argument in response to the SOC.

I don't think this helped at all- I don't know what it is that you want corrected.

[Pete53]

You need to copy the record and highlight the part needing correction and request that the correction be made with an explanation.

Unfortunately the person who has to ok the correction is the person who made the mistake.

[*Bergie*]

Does anyone know what form to use and how to make corrections to your VAMC medical records?

I had a false statement in my VAMC medical record. I tried the case manager for the clinic, who sent multiple e-mails to the attending. The doctor never responded, so I went to the patient advocate filled out their form and was eventually contacted by the IT guy. He made the corrections while we spoke on the phone then sent me a copy for my records. So I recommend you contact the patient advocate.

JMO,

Bergie

[Vync]

Berta,

I never knew that someone at the VA could help transcribe the chicken scratch handwriting that nobody can read. I'll have to look into that. They are going to be really busy...

Pete,

I asked my doc to add information that was completely absent, but occurred. The doc said that it was so busy that he cannot remember the details, so he just noted that as an addendum in my records. I guess my chances of a correction are out the window.

[Mcafee]

Hello All Hope All Is Well.

A rebuttal is all you need for this with the attached progress note in question I have found out.

or so have been advised by VAMC hope this helps.and the rebuttal is entered in the record.