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

[pacmanx1]

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 July 23, 2010 by pacmanx1

[Wings]

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

[chr49]

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 July 23, 2010 by chr49

[retiredat44]

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..

Edited July 23, 2010 by retiredat44

[retiredat44]

delete this double post thanx..

Edited July 23, 2010 by retiredat44

[retiredat44]

delete this, double post

thanx

Edited July 23, 2010 by retiredat44

[allan]

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.