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

[john999]

Let's face it. The VA's system is designed to CYA. My care has been poor or just almost adequate. The don't manage my DMII or pain worth a damn. The VA and the postal service have a lot in common. The VA loses vets like the post office loses letters. The VA owes us the best possible care. If we don't have a claim for the best care then who does besides Warren Buffet? They need to screen for homocidal tendencies if they keep up their standard of present care. The murder scene will be the pharmacy when they tell some vet "We can't fill your script and you doctor has gone home. Come back next week. Just because you have to drive 100 miles and wait 5 hours don't get mad".....bang!

[chr49]

x

x

x

I am going to make sure, from this day forward, that I have a HAND WRITTEN medical complaint/symptoms list for each and every medical appt. I attend at the VA. I am going to tell the doctor to put it into my medical record, or else hand-carry it over to the records dept. and tell them I want it added to my med record --do you think they will allow me to do this??? ~Wings

Don't know what they are supposed to do but they refused to take my list. The doctor was actually quite unhappy that I'd made a list, even though I told her it was because I forget what I need to tell them. She never documented any of my issues in my progress notes.

[chr49]

Good points!

"If I knew then what I know now"

1. State your pain as what it will be at its worst that day or time frame- I try to schedule my appointments in the morning when I'm 'freshest', so my 1-10 pain scale readings in the records don't reflect the amount of pain I'd be feeling later in the day/night.

This can bite you in the butt when making a case for your disability increase.

2. My medical records contain many errors/lies and/or misstatements- It'd be good to go through them and correct important information using that form allan posted:

3. The VA has a "flavor of the month" topic they'll ask questions about - right now it's suicidal tendencies, so everyone is being screened for that. Take whatever it is seriously and don't just give pat answers to get to your appointment (like I've done

Thanks for posting the link to the form Allan posted. I had missed that one!

[Notorious Kelly]

Thanks for posting the link to the form Allan posted. I had missed that one!

You're welcome, chr49- and thanks to Allan for finding it!

I'm fortunate that my NP keeps meticulous records so I was able to use Progress Notes almost exclusively and set aside labs, meds, etc cuz she had all that in Progress Notes.

On the down side, it's impossible to get her on phone so I've stopped by with a written note that is included in my records. Last one asked to cancel pain agreement since none of their meds have worked.

If Dr or anyone else isn't being cooperative I'd go to Patient Advocate and higher, as needed. Doesn't hurt to mention "I.G."

[Chuck75]

They certainly can be. I've noticed many "false statements" in my VA medical records.

Referrals never made.

Questions never asked that have answers.

Medical advice / instructions never given.

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/