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]

If you believe what your records say the VA gives you a comprehensive exam every time you see you PCP. This is just computer generated nonsense. You have to make a point of complaining about every condition you have when you see your doctor and nurse. I think many vets just assume that their issues are being addressed when they see their doctor. What is happening is CYA by the VA medical staff so it appears they are doing their jobs. When I see my private internist if he sees something he acts on it and informs me I have a problem. The VA just notes it and moves on to the next patient. I told them I had DMII. They never told me even though the lab results were in their faces. The care is so poor I wonder why I even bother except to get my licks in to support my worsenig disabilites. When you to to the VA for medical care it is good to have an agenda.

[stillhere]

I am guilty as the rest I really need to stay on top of this better. I always get copies of my visits every 1/4 at the VA ROI and some of the junk referring to PCP and even some specialists visit is a real crock and never happened.

What are we to do request another appt right after one we just had and confront them. Maybe this is a case where we all need to sit down with a patient advocate and question why this is going on?

[john999]

I just experienced a prime example: I had called my pain doctor at the VA to tell him the fentanly patches were not working. The VA waited four days to call me back saying that I had recently been to the VA where I reported zero pain. What the dumb SOB did not know was it was a dental appointment where the dental aide asked me if my teeth hurt. How the pain clinic can get my chronic pain disorder mixed up with a dental appointment and use that to justify not responding to my complaint about my pain meds I don't know. If I had not called them I would have run out of pain meds in July and the pain clinic had no appointment for me until September because I had zero pain. I fell right through the cracks and did not even know it. My civilian psychologist told me to call the VA about the fact the fentanly was not working. I just assumed I would see the pain doctor the first of August as usual and could discuss it with them then. Boy, was I wrong. I would have been twisted up in a knot due to VA's crazy system of automatic screens and bizarre communications. The pain doctor gave me an extension to call about my pain meds and asked me not to tell any other vet since it is secret. The pain doctors don't want to be bothered by patients except for the most persistent I guess. I have been in the pain management program for almost ten years and I finally get the secret to contacting my doctor.

[Vync]

I see this too. Some of the nurses ask me a lot of questions, but some don't. When I look at my records, the same questions are there, but they are all answered.

I went to the VA PCP yesterday for a problem and I was out of the room in less than three minutes. Comprehensive? lol

[Notorious Kelly]

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

[Wings]

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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

Edited July 24, 2010 by Wings