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Every Vet Please Read! Incorrect Recording Of Service Medical Records Left Vs. Right


VetDeniedSince1980s

Question

Has anyone ever dealt with their claims for disability being denied due to their medical records being recorded incorrectly? Left vs Right? I was injured in 1969 in my right leg in vietnam due to the recoil of a 105 howitzer by another soldier. An unfortunate accident. My leg was severely injured and fractured and was i hospitalized for almost three months. i healed up and was Released and honorably discharged.

almost ten years after i returned home a sore formed on my right leg that began to hurt severly. it opened up began to bleed, ooze, throb, and only got worse and worse. my primary doctor said this open sore was due to my leg being severly tramatized sometime before. the only trama i had ever received in either leg was in vietnam. a got a second opinion from another doc that stated the same thing. my leg had received trama before. so i began going to the va for treatment. the va treated my leg never indicating a diagnosis of the wound. i began my first claim in 1980. i found out that my service medical records indicated i was hit in my left. in 1985 i was denied.

fast forward to 2004 my leg was a huge gaping open sore that was almost unimaginable. went back to the va and was advised by the head nurse at the va wound care center that i had a severe venous leg ulcer. i spoke to her about my records and my previous claim. she said no you need to refile and re open your claim because a mistake has been made. this ulcer is caused by severe trauma from your service injury. i followed her instructions and refilled. with no other proof than several medical opinions and a few tests my 2nd claim was denied 2009 again due to my records indicating my injury happened to my left leg. they will not even consider a mistake could have been made.

fast forward again my leg is much better thanks to the head nurse who healed me with compression therapy. i have to wear a compression stocking the rest of my life or the ulcer will open back up. today i am 66 years old and have worked and fought for this compensation now for almost 35 years. i refilled one last time but with an attorney. VA has denied me again and now I am waiting on the statement of the case.

funny thing is all these years i have never had any proof of which leg was really hit. can you believe my daughter found the soldier in CA that accidently hit me in nam just this past week? and he remembers i was hit in the right leg cause it happened right in front of him.... he is preparing a statement for my case confirming that he is a witness and had direct involvement in my injury!!!!!

i need opinions from everyone who cares to comment on this? will VA ever admit that a mistake was made when my records were recorded? with now having a witness make any difference in the outcome of my claim??? has anyone ever dealt with incorectly recorded medical records??? After all these years now with representation and a witness do I have a chance at compensation???

Your Thoughts and Comments Please????

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VetDeniedSince1980s,

Have you actually carefully reviewed all of your service medical records? During the three month period you were hospitalized and during follow up exams after your hospitalization, it is hard to imagine that all of the medical personnel(doctors, nurses, techs, radiologists, physical therapists, etc.) incorrectly stated they examined and/or treated the left leg in their notes and reports when the injury was in your right leg. I can see one or two persons making a mistake but not all of the different medical personnel involved in your treatment. I might be wrong but I would think that a radiologist could differentiate between a left leg and right leg on Xrays and this would have been noted in the radiology reports.

If you have not reviewed your service medical records, I would obtain copies and review them ASAP. Make sure you have all of your service medical records. They should include the corpsman's report of your initial treatment in the field, reports of all medical personnel who had anything to do with your treatment while you were hospitalized in Vietnam and other hospitals overseas and stateside, reports of physical therapy after hospitalization, medical follow up appointments after hospitilization, etc. Often with injuries like you had, you would have been on a medical profile and on limited duty for a period of time. There should be copies of these records in your service medical records or in your regular service records.

I had a serious injury to my left shoulder while in Vietnam. I was treated by a Navy corpsman in the field and then sent to a field hospital in Danang where I remained for about a week. I was then transported to a naval hospital in Japan where I remained for another week, flown to a naval hospital in Maryland where I remained overnight and then flown to a naval hospital in South Carolina where I remained for over two months. I remained on a medical profile for over a year and had regular follow up visits at the base hospital at Camp Lejeune, NC. I am telling you this to point out all of the different medical facilities where medical reports were generated regarding the treatment of my injury from Vietnam.

I requested my service medical records from the national archives prior to filing my first VA claim. I only received part of my records and in the cover letter I received from the archives it stated more records might be found if I could be more specific about where I was treated. I provided more specific info listing everywhere I was treated and eventually received all of my medical records with the exception of the report of the Navy corpsman who treated me in the field and my overnight stay in Maryland. There are many notations through out my reports from numerous medical personnel who treated me at the different facilities. There were a couple of notations where someone listed my right shoulder as my injured shoulder but an overwhelming number of references were made regarding the injury to my left shoulder. Also, my profile and limited duty records stated left shoulder injury.

Have you reviewed your military medical exit exam for any mention of your right leg injury? Did you or anyone else ever take any photos of you after you were injured showing a cast on your right leg or being treated in the hospital, etc?

Again, I think there has to be some reports somewhere showing the injury was to your right leg rather than your left leg. Keep searching and don't give up.

Good luck and Semper Fi.

GP

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Georgiapapa has some great info above.

When did you first notice the mistake? it should have been reported it was your right leg when first found out they said it was your left leg?

but I understand we never think about things like that or this kind of a mistake!

I would say in my opinion if you get your buddy( hopefully) in the same unit, that will be evidence as eye witness and the VA should correct this mistake but however you still need a good attorney.

Vet DeniedSinsethe 1980's,

You may want to listen OR CALL IN to the hadit radio show tomorrow Wed 3-11-15 at 10:AM Eastern time.

Jerrel & Jbasser have a very experience Veterans Attorney Bob Walsh as the guest speaker...(you can ask questions) at the top of the hadit pages just click on hadit prodcast live and then clink on the show you may need to wait for a minute or so ect,,ect,, to pick up the broadcast!

Make the call you will be glad you did!

Here is the call in # 347-327-4819

..................Buck!

Edited by Buck52 (see edit history)
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You bet

"After all these years now with representation and a witness do I have a chance at compensation???"

Yes. I hope they go over the denials you received because they contain CUEs....if they rated for the wrong leg.

This is kind of bizarre no one caught this sooner.

Then again years ago a vet sued the VA and won because, he was sent into surgery for amputation of his right leg, as diabetes had caused gangrene and other complications to it.

He woke up only to look down and see they amputated the wrong leg.

"can you believe my daughter found the soldier in CA that accidently hit me in nam just this past week?"

Yep..our kids can be a tremendous help to us as they see things differently in the med recs, and also they know how to research the net well, when they get a challenge like looking for a Buddy.

Make sure the buddy letter conforms to the Buddy Info posts here at hadit.

My daughter, while in the Military, kept telling to open a AO DMII claim.

She didn't have any leave coming to get home for a while and would have reviewed my husband's med recs herself if I didnt finally get around to do that.

I was stunned.

She was right.

Award 2009 , AO DMII contributing to the death of my husband.

At the time . 2003, I was in a military school as a civilian and the homework was extensive and I was here too every day.I didnt want to even think about another VA claim.

But she was right.

I dont know how I did all that, time wise , but found considerable evidence for the claim and also I obtained 3 IMOs .

It brought more ancillary benefits to me than my past 1151 DIC award did.

And another extension to her DEA Chapter 35 eligibility date.And to mine.

They had paid my tuition at AMU under a past EED and that ran out.

After the DMII award, they paid me the additional 6 thousdand or more they owed, that I had to pay to finish my degree.

I think the Nehmer award was supposed to extend our Chapter 35 again.

Not sure ...I need to check that out.

I have been too busy to look into that but I will.

We have people in our families and among our friends that are willing and able to review our stuff.

The diary farmer I have farm business with, just came over with a contract he wants me to read.

2 other neighbors found a lot wrong with it and he wants my opinion to0.

He is being pressured a little to sign another windmill lease.

I have a windmill lease that is solid because I paid a real land lease lawyer to go over it years ago.

I think he should do that too, have a lawyer look over it, but the other 2 neighbors already caught stuff in it that does not seem kosher at all.

It is basically the same way how we have to handle stuff with VA , getting second lay opinions or research, , that might help us as your daughter helped you and then we all need to realize when we really need a lawyer for our claims..

Vet reps and VSos do not have the time nor be willing to take the time to really go over our stuff.

I think a college student would gladly do that,and even a high school student might for a small fee, just to try to seek specific things in SMRs and such.

How about your 201 Personnel Mil file?

And

"An unfortunate accident. My leg was severely injured and fractured and was i hospitalized for almost three months. i healed up and was Released and honorably discharged."

Did VA deny saying there had been no residuals to the accident?

Did they ever give you a "0" rating next to "SC" on older rating sheets?

"0" SC is FAR better then "0" NSC, but then again they rated the wrong leg. and if the right leg's residuals could have been rated at least at 10%, that is basis for a CUE occuring on the rating sheet, in my opinion, based on what you stated.

Can you CUE a disability that was not rated at all or even mentioned in the decision?

I did, but that was for both of my Nehmer AO claims.

Still, I think it is a CUE, if the medical evidence warranted that it be rated for the exact leg that was injured and if that evidence warranted at least a 10% rating.

You dont mean you were discharged under Medical HD discharge do you?

Did anyone in the USMC tell you to sign some bogus waiver saying you would never claim this?

Maybe just the Navy pulled that crap .decades ago.

Edited by Berta (see edit history)
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VetDeniedSince1980s,

Have you actually carefully reviewed all of your service medical records? During the three month period you were hospitalized and during follow up exams after your hospitalization, it is hard to imagine that all of the medical personnel(doctors, nurses, techs, radiologists, physical therapists, etc.) incorrectly stated they examined and/or treated the left leg in their notes and reports when the injury was in your right leg. I can see one or two persons making a mistake but not all of the different medical personnel involved in your treatment. I might be wrong but I would think that a radiologist could differentiate between a left leg and right leg on Xrays and this would have been noted in the radiology reports.

If you have not reviewed your service medical records, I would obtain copies and review them ASAP. Make sure you have all of your service medical records. They should include the corpsman's report of your initial treatment in the field, reports of all medical personnel who had anything to do with your treatment while you were hospitalized in Vietnam and other hospitals overseas and stateside, reports of physical therapy after hospitalization, medical follow up appointments after hospitilization, etc. Often with injuries like you had, you would have been on a medical profile and on limited duty for a period of time. There should be copies of these records in your service medical records or in your regular service records.

I had a serious injury to my left shoulder while in Vietnam. I was treated by a Navy corpsman in the field and then sent to a field hospital in Danang where I remained for about a week. I was then transported to a naval hospital in Japan where I remained for another week, flown to a naval hospital in Maryland where I remained overnight and then flown to a naval hospital in South Carolina where I remained for over two months. I remained on a medical profile for over a year and had regular follow up visits at the base hospital at Camp Lejeune, NC. I am telling you this to point out all of the different medical facilities where medical reports were generated regarding the treatment of my injury from Vietnam.

I requested my service medical records from the national archives prior to filing my first VA claim. I only received part of my records and in the cover letter I received from the archives it stated more records might be found if I could be more specific about where I was treated. I provided more specific info listing everywhere I was treated and eventually received all of my medical records with the exception of the report of the Navy corpsman who treated me in the field and my overnight stay in Maryland. There are many notations through out my reports from numerous medical personnel who treated me at the different facilities. There were a couple of notations where someone listed my right shoulder as my injured shoulder but an overwhelming number of references were made regarding the injury to my left shoulder. Also, my profile and limited duty records stated left shoulder injury.

Have you reviewed your military medical exit exam for any mention of your right leg injury? Did you or anyone else ever take any photos of you after you were injured showing a cast on your right leg or being treated in the hospital, etc?

Again, I think there has to be some reports somewhere showing the injury was to your right leg rather than your left leg. Keep searching and don't give up.

Good luck and Semper Fi.

GP[/quote

G,

Thank you the info you have provided has been so helpful. Unfortunately until now I had not done a proper search for my clinical records. Only going by what VA stated. I just received a copy of my c file and the only clinical records on there are the cover letters from the three hospitals indicating the left leg. SMH It is my own fault for never checking further into my records.

I just submitted to the archives a request for all my clinical records from the three hospitals now that i know which ones and where they were in vietnam. I should have obtained this years ago but i never really knew how to go about doing it. my daughter is on it and is helping me greatly!!! We now changed attorneys one who seems to be a better fit and has a passion for helping veterans like myself. We meet on wednesday to discuss my case going forward. He said that now having the witness and his statement along with the catscans they are going to perform on both my legs on wednesday as well hopefully will benefit us greatly. also I am scheduled to see a vascular doctor for my vein insufficentcy.

I should have gotten an attorney a long time ago along with searching for my records. and G you mentioned Japan. They told me I was headed to Japan and wasnt going back to my unit. I was relieved I was not going back to that hell. Turns out they released me back to my unit and said I was good to return back and finish my service in the field. When I returned back to my unit they said what are you doing here? they told us they were sending you to Japan? I said they told me that was where I was going too. They told me they were instructed to box up my belongings and send them to Japan. So all my stuff was gone. Everything. Letters, pictures, camera, etc. They put a tracer on my box but it was never recovered. They did reimburse me with a check for my belongings many of those things could not be replaced. Do you think perhaps some of my clinical records could have been sent to Japan? If so how do you think I can search to find out for sure. Would that be conducted thru archives as well? I have no idea in Japan where they were going to send me.

You are correct not all of my records from all the personnel should indicate the left leg. The is bound to be some indicating the right somewhere. Hoping I find what I am searching for thru archives now with the accurate facilitys and locations.

Thank you for your reply. Will update hopefully with good news once I receive all my records.

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VetDeniedSince1980s,

I don't know what to tell you in regards to your clinical records that were shipped to Japan. Perhaps they will show up in the records you obtain from the archives.

As a Vietnam veteran, I appreciate your daughter trying to help you with your claim. You have a good daughter. I just commented in another post about a good son helping his father with his claim. The father was also a Vietnam veteran.

Good luck on your search and I wish you and your daughter good luck with your claim.

GP

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Sadly, This happens frequently enought there is actually a regulation which addresses it. Remember, there are 2 parts to this and the VA will likely make you go through both parts: 1. Getting Service connected, along with a disability percentage and 2) getting the effective date you deserve.

Expect that you will have to fight VA tooth and nail on both issues, and you wont likely be disappointed:

3.156 New and material evidence.

(a) General. A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.
(Authority: 38 U.S.C. 501, 5103A(f), 5108)
(b) Pending claim. New and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed (including evidence received prior to an appellate decision and referred to the agency of original jurisdiction by the Board of Veterans Appeals without consideration in that decision in accordance with the provisions of § 20.1304(b)(1) of this chapter), will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period.
(Authority: 38 U.S.C. 501)
© Service department records.
(1) Notwithstanding any other section in this part, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim, notwithstanding paragraph (a) of this section. Such records include, but are not limited to:
(i) Service records that are related to a claimed in-service event, injury, or disease, regardless of whether such records mention the veteran by name, as long as the other requirements of paragraph © of this section are met;
(ii) Additional service records forwarded by the Department of Defense or the service department to VA any time after VA's original request for service records; and
(iii) Declassified records that could not have been obtained because the records were classified when VA decided the claim.
(2) Paragraph ©(1) of this section does not apply to records that VA could not have obtained when it decided the claim because the records did not exist when VA decided the claim, or because the claimant failed to provide sufficient information for VA to identify and obtain the records from the respective service department, the Joint Services Records Research Center, or from any other official source.
(3) An award made based all or in part on the records identified by paragraph ©(1) of this section is effective on the date entitlement arose or the date VA received the previously decided claim, whichever is later, or such other date as may be authorized by the provisions of this part applicable to the previously decided claim.
(4) A retroactive evaluation of disability resulting from disease or injury subsequently service connected on the basis of the new evidence from the service department must be supported adequately by medical evidence. Where such records clearly support the assignment of a specific rating over a part or the entire period of time involved, a retroactive evaluation will be assigned accordingly, except as it may be affected by the filing date of the original claim.
(Authority: 38 U.S.C. 501(a))
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Here's an interesting story akin to this. Marine goes ashore in 68 at DaNang for liberty off the USS Long Beach (CGN-9). Gets drunk and buddies convince him @ 0200 it would be a really good idea to get big naked lady tattoo on right upper arm (RUA). Vet has tattoo done and Commanding Officer is not the least bit impressed. Vet has planned on being a teacher when he gets out and, now sober, see the buxom lady on his right shoulder as a future problem. Vet has tattoo painfully removed in small sections by ship's medic and sewed up over several months. It leaves a biiiiig scar. All is documented in the SMRs. Vet gets very ill in 2002 and diagnosed with Hep C . Applies to VA for comp. Med recs list tattoo on LUA (left upper arm). He loses all the way to the BVA (from 2002 filing to 2010 appeal) but on the way finds ship's medic who removed it at CGN-9 reunion. Buddy letter falls flat because VA examiner says nobody can remember back 40 years. Additionally, buddy's letter provides no proof he was aboard CGN-9. At the BVA hearing, the Vet provides medic's DD214 showing proof of assignment as medic to CGN-9. Vet rolls up sleeve and shows scars of tattoo removal to VLJ. Vet rolls up left sleeve to reveal ...nothing. Vet wins. Moral of story? Tattoos happen... usually early in the morning in the presence of extreme ETOH. Beware Marine buddies with good intentions on shore leave.

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Dang, I really need to get a complete copy of my med jacket. I fell down a flight of cement stairs on day 5 of boot camp. Landed knees first. Fast forward a bit, developed a cyst behind L knee that feels like a hot coal when it flares up. MRI at Camp Lejeune in 94 confirms it. Jump ahead to mid 2000, 18 months of VA runaround finally sent to Philly, surfer dude from Baywatch moonlighting as an orthopedic dr shows me my X-ray with a 2 inch scar where my knee cap had been fractured! Only got 10%, but was happy, finally got them to see the light. Now I need those records to ensure they have the correct knee indicated before seeking an increase. I hope and pray you are successful in your persuit and vindicated!

Semper Fi!

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