New PCP problems

[hurryupnwait]

I recently moved and had my first appointment with my assigned PCP.  Well, I just downloaded and printed his notes, he has made several statements about tests that he DID not do, i.e. straight leg lift, post void residual.   These statements are not in my best interest.  I also stated that I did not think that the omeprazole was still working. He then said that I should stop taking them, but in his notes, he states that  my "reflux symptoms have disappeared" and then later he states "He is not taking his medication for GERD as his symptoms have gone away". Should I contact him and ask him about these entries or should I just let it go?  These notes relate directly to SC issues and potentially SC issues, GERD.  I have called another clinic nearby and asked to be placed on their waiting list for new patients when they hire a new doctor.

 

 

Happy Trails

 

Paul

[RUREADY]

I recently moved and had my first appointment with my assigned PCP.  Well, I just downloaded and printed his notes, he has made several statements about tests that he DID not do, i.e. straight leg lift, post void residual.   These statements are not in my best interest.  I also stated that I did not think that the omeprazole was still working. He then said that I should stop taking them, but in his notes, he states that  my "reflux symptoms have disappeared" and then later he states "He is not taking his medication for GERD as his symptoms have gone away". Should I contact him and ask him about these entries or should I just let it go?  These notes relate directly to SC issues and potentially SC issues, GERD.  I have called another clinic nearby and asked to be placed on their waiting list for new patients when they hire a new doctor.

 

 

Happy Trails

 

Paul

I would ask him to get his notes right and not what he want to write. RU

[Buck52]

Most all VA Dr's do this type of thing   its just flat out lying or covering there butts.

I'd make copies of the notes and take them to him/her and ask why he said this?  , and explain to the Dr what you meant, if he misunderstood you or says they must be an miss understanding, then ask politely for him/her to listen to you better and get things right....you hold your health  in a serious way and you expect a Professional Dr to do the same. never mention a claim to your PCP unless you trust him/her.

 

I take notes during my visits

 

jmo

......................Buck

[green]

I would log onto myhealthevet and send a secure message stating the error in the notes directly to your new PCP, even ask that he amend his notes.  Reason I suggest this is it will become part of your myhealthevet blue button notes. 

Someone recently posted the process for submitting a formal complaint/appeal for incorrect notes on this site.  I'd do a search to see if you can find it.

[broncovet]

1.  You can dispute errors in your medical records. Source:  https://www.law.cornell.edu/cfr/text/38/1.579

§ 1.579 Amendment of records.

(a) Any individual may request amendment of any Department of Veterans Affairs record pertaining to him or her. Not later than 10 days (excluding Saturdays, Sundays, and legal public holidays) after the date or receipt of such request, the Department of Veterans Affairs will acknowledge in writing such receipt. The Department of Veterans Affairs will complete the review to amend or correct a record as soon as reasonably possible, normally within 30 days from the receipt of the request (excluding Saturdays, Sundays, and legal public holidays) unless unusual circumstances preclude completing action within that time. The Department of Veterans Affairs will promptly either:

(1) Correct any part thereof which the individual believes is not accurate, relevant, timely or complete; or

(2) Inform the individual of the Department of Veterans Affairs refusal to amend the record in accordance with his or her request, the reason for the refusal, the procedures by which the individual may request a review of that refusal by the Secretary or designee, and the name and address of such official.

(Authority: 5 U.S.C. 552a(d)(2))

(b) The administration or staff office having jurisdiction over the records involved will establish procedures for reviewing a request from an individual concerning the amendment of any record or information pertaining to the individual, for making a determination on the request, for an appeal within the Department of Veterans Affairs of an initial adverse Department of Veterans Affairs determination, and for whatever additional means may be necessary for each individual to be able to exercise fully, his or her right under 5 U.S.C. 552a.

(1) Headquarters officials designated as responsible for the amendment of records or information located in Central Office and under their jurisdiction include, but are not limited to: Secretary; Deputy Secretary, as well as other appropriate individuals responsible for the conduct of business within the various Department of Veterans Affairs administrations and staff offices. These officials will determine and advise the requester of the identifying information required to relate the request to the appropriate record, evaluate and grant or deny requests to amend, review initial adverse determinations upon request, and assist requesters desiring to amend or appeal initial adverse determinations or learn further of the provisions for judicial review.

(2) The following field officials are designated as responsible for the amendment of records or information located in facilities under their jurisdiction, as appropriate: The Director of each Center, Domiciliary, Medical Center, Outpatient Clinic, Regional Office, Supply Depot, and Regional Counsels. These officials will function in the same manner at field facilities as that specified in the preceding subparagraph for headquarters officials in Central Office.

(Authority: 5 U.S.C. 552a(f)(4))

(c) Any individual who disagrees with the Department of Veterans Affairs refusal to amend his or her record may request a review of such refusal. The Department of Veterans Affairs will complete such review not later than 30 days (excluding Saturdays, Sundays, and legal public holidays) from the date on which the individual request such review and make a final determination unless, for good cause shown, the Secretary extends such 30-day period. If, after review, the Secretary or designee also refuses to amend the record in accordance with the request the individual will be advised of the right to file with the Department of Veterans Affairs a concise statement setting forth the reasons for his or her disagreement with the Department of Veterans Affairs refusal and also advise of the provisions for judicial review of the reviewing official's determination. (5 U.S.C. 552a(g)(1)(A))

(d) In any disclosure, containing information about which the individual has filed a statement of disagreement, occurring after the filing of the statement under paragraph (c) of this section, the Department of Veterans Affairs will clearly note any part of the record which is disputed and provide copies of the statement (and, if the Department of Veterans Affairs deems it appropriate, copies of a concise statement of the Department of Veterans Affairs reasons for not making the amendments requested) to persons or other agencies to whom the disputed record has been disclosed. (5 U.S.C. 552a(d)(4)) (38 U.S.C. 501)

[47 FR 16324, Apr. 16, 1982]

 

 

2. You can change docs if you think this doc is inadequate. 

[green]

Thank you broncovet

[USMC_VET]

I would log onto myhealthevet and send a secure message stating the error in the notes directly to your new PCP, even ask that he amend his notes.  Reason I suggest this is it will become part of your myhealthevet blue button notes. 

Someone recently posted the process for submitting a formal complaint/appeal for incorrect notes on this site.  I'd do a search to see if you can find it.

I agree with Green.  This is your best course of action.  Lets say you go see them face to face again and you explain.  If they say yes yes yes ok your right, then you ahve to wait and HOPE they get your records right. 

As stated by green by sending a Secure message to your PCP your concerns can be addressed to him as well as having those concerns become part of the official medical records. 

I would write them and do a point by point discussion. Keep it factual no emotions. 

"After my visit on XX/XX/XXXX i checked my exam notes and noticed some discrepancies regarding what was discussed and what was recorded.

1)Acid Reflux:  I conveyed that the omeprazole was currently helping to reduce the symptoms associated with GERD.  In the notes it states that I was no longer taking my medication and that my symptoms had dissapeared.  This is not entirely accurate.  I am currently taking my medication and did not go stop taking the medication prior to the visit.  I also wish that the record reflect that the symptoms have been dissipated and are helped by the medication but they have not disappeared entirely.

2) The Notes state that multiple tests were conducted, however we did not conduct the following.....etc etc

 

I realize that the clinic has a multitude of patients and that its possible that another patients exam might have been similar to my own which would account for the discrepancies noted above.  Please feel free to contact me regarding the following at 123-45-6789.  I also wish you to know that i am very detail oriented about what is and is not in my record so i wanted to let you know I would also be requesting that the VA ammend my medical records and will be sending that request to them once we have a chance to talk about it.  Thank you Sir.'

 

Keep it cordial and when dealing with someone from the VA that has screwed up that you always use the adage "never attribute to malice that can be attributed to ignorance."  By that i mean when you TALK TO THEM be defferential like i was above and say "oh im sure it was jsut a mistake, etc."  dont be confrontational.  The time to be confrontational and passive aggressive is once they DONT DO THE RIGHT THING.  Then you use the law and their own regs to MAKE them do what THEY SHOULD HAVE DONE IN THE FIRST PLACE.  Even at this point, and at every point NEVER YELL,SCREAM, CURSE, ETC.  You do not want to go through what others have where they are labeled "dangerous" etc and require escorts.