PCP Writing Bad Notes in Medical Records

[Punisher3A1]

When I check my notes after a visit to my PCP in My HealtheVet, I have noticed a few times where the notes she writes are nothing we have talked about and some are wrong.  Is there a way to amend my VA medical records.  I have already submitted a change of provider request but I am wondering if it is even possible or something I should just talk to my new provider about?  In my notes from January 14, 2016 my PCP wrote "NOTED HIS CLINICAL EXAM WITH NOT MUCH FINDINGS BUT C/O ARE OUT OF PROPORTION".  How could she put something like this in my notes?  How is it acceptable to write this and in all caps?  She doesn't know my pain level or how many times I use the bathroom every day.  This time I brought my fiancé with me to my exam because she almost didn't believe me when I told her how my PCP acts and what she says.  I now plan on having her there for all of my appointments so that I can have a witness.  One complaint was with my back and she didn't look or even touch my back but in my notes it said I have full range of motion.

 

Please let me know if any of you have had any successes with this problem because I know I can't be the only one this has happened to. 

[pwrslm]

Go to the Release of Information Officer/Privacy officer at the VAMC where your PCP is.  They have a form for you to request the correction.

 

The VA is obligated to give you a different PCP on request.  They don't like it, but its the law.

 

These records contain notes that are opinions of medically trained people.   Correction of facts misrepresented is possible, but if the PCP gives an opinion, then it may not be possible.  If you disagree with the diagnosis of the PCP physician, and cannot talk with him/her to resolve the issue, you should go to a patient advocate to document the disagreement and possibly broker a reasonable solution that gets you the care and proper diagnosis that you should have.

Edited January 18, 2016 by pwrslm

[ArNG11]

Agreed.  This is not by accident and not something new.  VA and VAMC and personnel a like are trying to overcome how much information is out there for Veterans and dependents to protect themselves.  

The only way things are going to change is if we challenge them and bring them out in the open.  

If it is not resolved at the VAMC, do not hesitate to go up the chain.  Eventually someone with authority will get the point and this situation won't repeat again.

[broncovet]

38 cfr 3.1579 explains it, as follows: 

§ 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.

Edited January 18, 2016 by broncovet

[Salathiel]

With the trend to outlying clinics staffed by NPs you are wise to take a witness with you.  I have just informed my wife she is going to be with me on any appointment except to the hospital and for similar reasons plus.

[Buck52]

Take copies to your PCP and before you ask about it, ask her what you guys talked about the last time you were there on this date...see what she says first   and if she don't mention the things in her report  of myHealthVet  then whip them out and ask her kindly   well If that's all we talked about   then why did you write this?   and ask her  this is your report correct?

Then ask her in a nice way to amend these statements...I don't think they can take them out of the Notes but they can amend them.

its better to try to get this solve with your PCP other than just get a new PCP  solve this issue first and then request another PCP.

They will want to know why...this is your chance to let them know how well the healthcare is at your VAMC.

I did this with one of PCP RN 's

I wish you the best.

 

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