Jump to content
Using an Ad Blocker? Consider adding HadIt.com as an exception. Hadit.com is funded through advertising, ad free memberships, contributions and out of pocket. ×
  • 0

Are Pre-Programmed False Statements On Veterans’ Medical Records Being Used To Deny Claims?


pacmanx1

Question

Are Pre-Programmed False Statements on Veterans' Medical Records being used to deny Claims?

July 22, 2010 posted by Terry Richards

Pre-Programmed False Statements on Veterans' Computerized Medical Record Progress Notes whether being used by the VA intentionally or unintentionally to describe the Veteran-patient's true medical condition or its "residuals," are or could be used as a "basis to deny" Veterans' service-connected and non-service connected disability claims, federal tort claims, and social security disability insurance claims, among other things.

"FALSE STATEMENTS" ARE A VIOLATION OF: TITLE 18> PART 1 > CHAPTER 47 > SECTION 1035, ET SEQ., AMONG OTHER THINGS.

Below are samples of "Pre-Programmed" statements that you may find on your written or electronic "Medical Record Progress Notes" that may or may not be accurate. Paragraphs 1 through 8 set forth below are the ones if not accurate, could most likely cause your claim 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.

1. "This patient denies any other new medical problems."

2. "The patient 'DENIES' both short-term and long term exercise intolerances."

3. "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, facial rash, Gottron sign, v-sign, and shwal sign."

4. "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."

5. "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."

6. "The tests were reviewed with the patient."

7. "Otherwise the patient has no further medical complaints.

8. "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.

http://www.veteranst...to-deny-claims/

Edited by pacmanx1
Link to comment
Share on other sites

  • Answers 17
  • Created
  • Last Reply

Top Posters For This Question

Top Posters For This Question

Recommended Posts

  • HadIt.com Elder

x

x

x

Very significant research article, something to think HARD about. Thanks for posting it Pete992. ~Wings

Link to comment
Share on other sites

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.

http://www.veteranst...to-deny-claims/

While my wife and I were going thru my VA medical records we found multiple errors, especially in my primary care progress notes. There are several PTSD screens that were supposedly done by nursing staff showing a negative PTSD screen(I'm 50% SCed). The funny thing is, I've never been asked any of the listed questions by any nurse. We found several other errors, especially in my primary care progress notes.

So....I'm assuming that this must be happening to everybody. If so, just how do you address the problem? Who do you see? If others have as many as I do, it seems like this could be a never ending source of problems. I haven't been in the VA medical system that long.

Edited by chr49
Link to comment
Share on other sites

wow!

what a coincidence this is being brought up now..

I ordered copies of al my medical rescords from when I was in the hospital for six months..

I was reading through some progress notes..

mind you I have progress notes that are in huge boxes..

I read some notes that said

'patient says he is not in pain'

patient was joking with nurses'

'patient was interest in how the machine's electonics worked'

'aliens fling out of my butt'

(the last one I was probably making a joke in jest about my medical problems, and was actually written down, for al I know I didn't say it... it would be veyr difficult to say when, where and why, but being in the condition I was in lying in my deathbed, on Duilded or Morphine and hooked up to several machines... a statement like that could make you sound like a total nutcase..)

I have thousands of pages and way too much to read through and figure out what the hell is going on in these notes..

I was kinda shocked because astatements can be taken out of context when you say something, or don't say something...

I was freaked out when I was reading a few pages.. Imagine how some person could read those that have no idea what the context was..

I would have to go back and think about where, who, what, where, when, and what was said to who and why..

if I was lying there for 6 months in bed on every drug known.. and said anything, and if it wass written down.. anyone could take those statements to think whatever they wanted to think without context..

and what if soemone writes down something that was wrong, sisad by the wrong person, or the patient had no idea a joke made in pain or jest can be used against them..

:wacko::blink::ph34r:

Edited by retiredat44
Link to comment
Share on other sites

Posted (edited) · Hidden by Pete53, July 23, 2010 - double post
Hidden by Pete53, July 23, 2010 - double post

delete this double post thanx..

Edited by retiredat44
Link to comment

delete this, double post

thanx

Edited by retiredat44
Link to comment
Share on other sites

  • HadIt.com Elder

When it comes to my decades old diagnoses of hypertention, i'm seeing comments like,("WHITE COAT HYPERTENTION") in my med records. Thats just what it looks like in my records. Big capital letters in parenthasees.

I also have Dr's notes stating my HTN drops on retesting at the end of the visit. I've never been retested at the end of any Dr's visit for blood pressure. After being instructed by my dr to keep daily records of blood pressure, he trys to claim I don't even have HTN. That was stopped when I pulled out a yrs log showing him my high readings and med records showing he requested I keep records along with the prescription he provides for water pills to keep the swelling down in my feet and calves, due to HTN.

These VA Dr's forget all these things & think we're to stupid to keep records or carefully read them. They think all they have to do is follow VA raters instructions & that will be the end of it.

It doesn't work that way with me.

Link to comment
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.

Guest
Answer this question...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

  • veteranscrisisline-badge-chat-1.gif

  • Advertisemnt

  • How to get your questions answered...

    question-001.jpeg

    All VA Claims questions should be posted on our forums. Read the forums without registering, to post you must register it’s free. Register for a free account.

    Tips on posting on the forums.

    1. Post a clear title like ‘Need help preparing PTSD claim’ or “VA med center won’t schedule my surgery” instead of ‘I have a question’.
    2. Knowledgable people who don’t have time to read all posts may skip yours if your need isn’t clear in the title. I don’t read all posts every login and will gravitate towards those I have more info on.
    3. Use paragraphs instead of one huge, rambling introduction or story. Again – You want to make it easy for others to help. If your question is buried in a monster paragraph there are fewer who will investigate to dig it out.

    Leading to:

    Post clear questions and then give background info on them.

    Examples:

    • A. I was previously denied for apnea – Should I refile a claim?
      • was diagnosed with apnea in service and received a CPAP machine but claim was denied in 2008. Should I refile?
    • B. I may have PTSD- how can I be sure?
      • I was involved in traumatic incident on base in 1974 and have had nightmares ever since, but I did not go to mental health while enlisted. How can I get help?

    This gives members a starting point to ask clarifying questions like “Can you post the Reasons for Denial from your claim?” etc.

    Note:

    Your firsts posts on the board may be delayed before they show up, as they are reviewed, this process does not take long and the review requirement will be removed usually by the 6th post, though we reserve the right to keep anyone on moderator preview.

    This process allows us to remove spam and other junk posts before they hit the board. We want to keep the focus on VA Claims and this helps us do that.

  • Most Common VA Disabilities Claimed for Compensation:   

    tinnitus-005.pngptsd-005.pnglumbosacral-005.pngscars-005.pnglimitation-flexion-knee-005.pngdiabetes-005.pnglimitation-motion-ankle-005.pngparalysis-005.pngdegenerative-arthitis-spine-005.pngtbi-traumatic-brain-injury-005.png

  • Advertisemnt

  • VA Watchdog

  • Advertisemnt

  • Ads

  • Can a 100 percent Disabled Veteran Work and Earn an Income?

    employment 2.jpeg

    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

×
×
  • Create New...

Important Information

{terms] and Guidelines