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Operation Report


foreveryoung

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Can anyone tell me if there is and operation report required to be filled out after surgery? Something like, made incision 2 inches below this area, or found this abnormality etc. I was told by a VA surgeon I should have had one.

Thanks

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Yes- there should always be a surgical narrative done.

I think sometimes it is transcribed from a tape.

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  • HadIt.com Elder

Ask for copies of your progress notes usually on computer.

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Yes- there should always be a surgical narrative done.

I think sometimes it is transcribed from a tape.

If you are referring to a surgery operation type report, yes an operative report is always done. They are suppose to be done right after the surgery (according to my medical transcription class), but depending on how many cases the surgeon may have, they may do them later in the day with the notes from the surgery. But they should be done within 24 hours.

If this was some procedure done in a regular doctors office (i.e. mole removal, other in office procedures), it all depends on the doctor. It would be documented in the patients records, but not necessarily as an operative report, unless you went to a specialist.

You can go to the doctor or hospital who performed the procedure and request a copy of your records. According to the new HIPPA laws you are allowed to inspect your records and most doctors do not have a problem giving you copy of a report to give to another doctor.

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Thanks for the replies.

I should have stated this earlier, this operation was performed in Frankfurt General Hospital Germany in 1976. I have a copy of SMR but there are no reports, just a lab test of organ removed.

This operation was performed by a military surgeon with the rank of Major.

Is this something the VA should have reviewed and have had? Can this be grounds for CUE, for not providing or maintaining these reports? How can the VA make a well grounded denial if reports are missing?

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Guest jstacy

Operative reports are the property of the hospital and not the MD who performed it. The reports will be part of the hospital record and that is where you can find it.

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Only if they knew they existed-

You mentioned 'not well grounded' denial and I assume you did not continue to appeal that decision?

Have you attempted to get this report directly from the hosp in Frankfurt?

Was this the 97th General, or the University Clinic in Frankfurt or the General Hospital in Barmbek?

These hospitals- are all on the web-

This link might help too-

http://www.usarmygermany.com/Units/Medical...AHFrankfurt.htm

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Hi All,

I haven't been on the board in a few days...kids keeping me busy.

What you are looking for is your inpatient records. I don't know how long each facility keeps them and I don't know if the hospital in Frankfurt is still open. They closed a lot of facilities in Frankfurt. I know when I was in Germany the major hospital was Weisbaden, now it is Landsthul, which I lived in the village right next to it. I use to walk to Landsthul all the time (not the hospital...that hill would kill you, but the village).

I have had to request inpatient records before from an Army hospital, but it was for a surgery I had a couple years prior.

If you have access to a military hospital or clinic, I would go to the medical records section and they would know how to request them or if they are still available at the hospital (they should know the time frames they keep the records at the hospital before they send them to St. Louis). Most likely, since it has been 40 years, they would be at NARA in St. Louis. I know that is where they send retiree's medical records if they are not going to use the military facilities. For inpatient records they usually keep them by the year the procedure was done, so you would have to provide that info. If you had multiple surgeries at the same facility, but during different years, they would have to look them up by the year and then the name.

Sometimes operative information gets put in your outpatient records (lab, pathology, sometimes even the surgical report), but the whole inpatient record is kept seperate from your outpatient record.

If they are in St. Louis, it might be better (I don't know if they charge for copies)...I know when I wanted a copy of my medical records because we where going to Germany, the army hospital wanted to charge me for copying it (leave a blank check....yeah right!!). My husband who was in the Air Force told the person who was doing my clearance to go to Germany and he had the clinic at the base make me a copy. Then the guy at the base told me just not to return the records, since we where leaving in a few days. The army hospital would have them listed as being checked out to the base. The Army didn't like you to hand carry your medical records, where the Air Force didn't have a problem with it at that time. My mom had to have her's sent when my dad PCS'd to Alaska and it took over a year for them to get up there from Virginia. They must have traveled the world.

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Were these reports also required for military hospitals in 1976?

Yes they where. I had surgery when I was 12 in 1976 at an Army hospital and years later I had to get a copy of my inpatient records to show the Air Force that I was in one piece to go to Germany, because what the Army doctors said I had. Years later I had Air Force doctors and cilvilian doctors say they thought I was misdiagnosed, because the condition they said I had would not have gone away by itself. The Army doctors told my parent's I would "Outgrow it".

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The VA has already granted my claim without these reports. Which was a long time coming. I am working a CUE issue now. But when I had my C&P about 4 years ago the VA surgeon stated that he could make a better decision if he had my Operative Report. I had so many other Doctor statements to confirm my claim it made it hard for VA to deny. This went to the VA for review and later approved.

Is it possible the VA knew the reports were missing or didn't have time to track them down?

Edited by foreveryoung
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Guest jstacy

They probally didnt want to track them down. I have had th at happen to me in the past and have presented OR reports. Let me say th ie, OR reports are very detailed play by play and in my case it was the deciding factor as the C @ P examiner looked at it and used the term most likely to have occurred.

Get the report and submit it. The Hospital in Germany should have it.

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Foreveryoung- does your CUE somehow circumvent the constructive rule in Bell V Derwinski?

WHat I mean is did they give you the wrong diagnostic code prior to 1992?

Bell V Derwinski

"In Bell v. Derwinski, 2 Vet.App. 611, 613 (1992) (per curium order),

the Court noted that where "documents proffered by the appellant are within the Secretary's control and could reasonably be expected to be a part of the record `before the Secretary and the Board,' such documents are, in contemplation of law, before the Secretary and the Board and should be included in the record." Bell noted that, if such documents could be determinative, a remand for readjudication would be required. Here, the disputed items would probably not be considered determinative, thus requiring a remand, but they are

relevant and should be included in the ROA if they were in the Secretary's "control" so as to charge him with either actual or constructive knowledge."

From: Simington V Brown-

Prior to this per curium order in Bell, as I understand this-the facts and medical evidence had to be in VA's physical possession at time of alledged CUE.

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I have a BVA hearing next week where I plan to bring up some CUE issue I believe they made in 1980 and 1992. In my BVA ruling in 1980 I believe they may have given me the wrong diagnostic code. I have alot of last minute cramming to do. I hope all goes well when the time comes.

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I wonder if the BVA would address a CUE unless this is part of your appeal already-

Myler V Derwinski- the VA failed to assign the proper percentage rating based on the medical evidence they had-in 1953 and the veteran successfully proved CUE in 1991.

The VA had assigned a "0" % rating for a through and through gun shot wound.

The medical evidence in 1953 showed evidence of disability to "at least a moderate degree" as the GSW went through muscle Group XIII.

In this case the veteran had medical evidence in the file in 1953 of the disability and the CUE occurred in the rating and the diagnostic code.

Edited by Berta
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Yes, this is part of my appeal.

DON20906

Did you ever receive the emails I sent you off line, or were you not able to answer them?

Edited by foreveryoung
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Guest frank
Can anyone tell me if there is and operation report required to be filled out after surgery? Something like, made incision 2 inches below this area, or found this abnormality etc. I was told by a VA surgeon I should have had one.

Thanks

on my navy discharge,it states what scars i have on my body,look on your discharge. frank
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Guest frank
Should the VA have had them?
hi everyone,i have progress reports,from hospital in japan,i got these went va sent me my records,they claim the have no medical records,of why i was there ,the progress reports state daily doctors vists,also signed by doctor would something like this help you ? frank
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My DD214 has nothing on it about this operation, Thanks.

I have 4 parts to my CUE that is one of them. If these records every existed they should have been part of my service medical records, Right. Some how they were lost or distroyed. Because these are records that should reasonably be part of my SMR, as other enteries were from this operation. The VA did not have them to review to grant my initial claim. Would this fall under 38 C.F.R. 4.130 or 38 C.F.R. 3.303(a) ?

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