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Just haphazard, bewildering C&P exam. What happened? What can I do?

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aoneinsun

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Hi,

I had an interesting and bewildering C&P exam with a Dr. covering three items of evaluation; lower extremity varicose veins, piriformis syndrome (left hip), and lumbar condition with herniation (for a disc bulging 5 mm to the left at L4-L5).

 

Here is about how it went…

Firstly, I had filled out the summarized history questions for each of the three items. The papers I had diligently filled out simply laid on his desk the entire exam though, and he simply asked me questions as he went through his DBQs. I was very well versed in my medical record and could tell him the brief history (or development) of each condition (along with my medications) in a quick, concise fashion. He was reasonably personable, and he seemed to be pretty pleased with my being quick and to the point (it was towards the end of the day and he was delayed in getting to me). And he seemed to whip through the DBQs with speed. He did inspect my legs for varicose veins (which are really obvious). I was surprised that he didn’t ask if I had aching and fatigue in my legs after prolonged standing or walking or if the compression hosiery I was wearing was helping. He could have found out the answers to those questions if he had read the packet I filled out (he didn’t bother to read that it seemed, nor did I get sense that he read my medical record). I had to specifically say that I had aching while standing for long periods of time, and I didn’t realize I had varicose veins for years until recently. I think he should have asked me that when filling out the Artery & Vein Conditions DBQ at 3B. And I hope he filled that part out…

I also explained how I had hip/low back issues after some long runs and landing weirdly on my left leg while playing volleyball. He had me walk (which is in my case limp, barely putting my left foot forward to step) to the office door and back to see my gait. He had me try to lean backwards, forwards, side-to-side, and twist. I could do all pretty well except the leaning forward to touch toes. I could only lean forward maybe 15-20 degrees. I glanced at his notes, and they almost all looked like they said 30 degrees (normal) except I don’t know what he put for forward flexion (I saw nothing but 30 degrees on the sheet, and I don’t know if he put something down later to give an accurate reflection of my forward flexion). I’m wondering about this because the Back (Thoracolumbar spine) conditions DBQ specifically says in Section III (before 3A) to “Measure ROM with a goniometer.” In fact it says 3 repetitions of ROM (at a minimum) are needed. I only did forward flexion twice, and that was because the first time I leaned over he didn’t seem to like it that I couldn’t lean down very far, and so he stood up and showed me how to lean down to touch one’s toes to demonstrate what he was looking for from me. Again I leaned down about as far as I could without pain (which was not much). I don’t know what he wrote down, and I never saw a goniometer once in the exam. Should he have used a goniometer?

He didn’t examine me at all, as in seating me on the table, having me attempt to perform straight leg raise tests (which is required at step 12) or palpating for tenderness, etc. It was most like a reporter’s interview (aside from him observing me having trouble touching my toes and him encouraging me to try to do it). One thing he did do that I thought was indeed good was to run a pointy object up and down my legs while I was seated. Interestingly, I had slightly less sensation on the left leg, and I told him this.

He also didn’t test my hip flexion, or ankle flexion/dorsiflexion, great toe extension, etc, which is required per the DBQ at step 8A. That seems like that would have been a pertinent thing to assess, especially after observing how small of a step I took with my left foot while demonstrating walking for him. And he was supposed to test for piriformis syndrome (left hip) during this exam, and I even told him that just last week I was also diagnosed by the VA Pain Mgt clinic with IT band syndrome of the left hip for my tension and pain along the outside of the left hip. I have no idea what he put for ROM for my left hip...

He got to the end of the last DBQ form that he whipped through (after skipping what I think are essential parts), and then he finished the exam abruptly saying, “Well, that’s it. That’s all. We are done.” When I asked if there was anything else, he was like “No. That’ll do.”

At the end of the exam, he seem to notice the envelope full of the papers I had filled out along with my medication list I had diligently prepared. He was like, “What’s this”? I was like, “That is for you, which my medication list and everything.” He acted like “Oh,” and seemed to grab it and take it somewhere. I wonder what he did if anything with that. He seemed to be completely done with me at that point.

 

My Questions:

How can I get record of his notes and when might they become available? 

Is this super relaxed approach, and skipping through what I think are required sections normal? Is this anything like how a C&P exam should go?

Is this lack of use of an accurate measuring device going to lend itself to an accurate rating? Should I document that he did not use any accurate measuring device and have my own physician measure my ROM with a goniometer (or would that come later with a VA attorney after the VA denies my claim)?

 

 

What just happened? Was I supposed to be somehow more demanding during the exam, and if so how could I have done so appropriately?

 

 

Any advice appreciated!

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The DAV has recently said that results of C&P exams are no longer releasable until after a decision has been made.  We have tried multiple times to get copies of mine and well as my wife's with the same answer from two different DAV reps.

Travis

 

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  • HadIt.com Elder

It depends on where and who did the C&P

Usually if the VA does your C&P at your VAMC, You wait a week or two and go to Information release of records sign a FOIA  and they can print it off for you.

If your C&P is contracted out by the VA (QTC for me) then after the C&P its a little longer wait or you can fax the company to send you the results or check with your VAMC BVA. (Benefits Veterans  Administration.)

I have did both and believe me its worth the $$ try to get that C&P Report before your decision.

Especially Nowdays if you use the internet....> (My Healthevetvet/Ebenfits)

jmo

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

Edited by Buck52
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nasty business those gremlins who play like medical professionals....

 

The C&P exam creates a medical record, you have a right to a copy of that record under HIPAA laws.  Patients have the right to ask for a written notice about how their health information is used and shared, and to view their medical records. They can request a copy of their file, and also request that any mistakes be corrected. In most cases, health care providers must produce these documents within 30 days of receiving the request, but may charge reasonable fees to cover any expenses associated with making copies, if these are requested by the patient. Go to the ROI office at the local VA and put in a formal request, not even VA policy can violate HIPAA.  They do not have a right to with hold your medical record from you, ever.

 

You are also protected by State laws as well, for example, they must provide you copies if you ask for them within 5 days in California...

 

 

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Thanks. I did not quite realize that I had those good options for seeing my record. I think it prudent to know what the Doctor's notes were at least (and to know sooner rather than later). I will request the record.

My other thought in wanting to know soon is, should I have an independent medical professional actually use a goniometer (since this has never been done to date) to measure the ROM? My one year after leaving active duty is coming up at the end of April. I understand there is a presumptive period 1 year after leaving active duty wherein limitations/chronic issues are presumed to be attributable to active duty. Would it be prudent to get accurate goniometer measurements performed while I am within the 1 year (rather then wait a few months and fall outside that timeframe)?

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  • HadIt.com Elder

If it was me I think I'd Gamble on it  if they didn't use the correct device to measure ROM During your C&P Exam  &rate or deny you thats Assuming/guessing&a NO NO so you could CUE THE DECISION if your not satisfied with it  denied or low balled.

you would need anIME from a private Specialist to TRUMP the VA Examiner  and if any of the Private Dr is more positive than the VA Doc  then you can use Equipoise .

Equipoise is used in a 50/50 split decision and usually goes to the veteran.

jmo

.........Buck

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I just checked with QTC, and they say that I cannot request the C&P exam Doctor’s notes directly from them. QTC said that after my third and final C&P exam on April 6th, they will bundle everything together and send to the VA. Thereafter, I would then have to request the Doctor’s notes from the VA. Thus, I will not know what the C&P examiner (who I know did a haphazard exam) really said for quite some time.

My main concern is if the hip Range of Motion was properly documented (since the examiner did not check for it (nor did he use a goniometer). I have heard that limitations should be documented within the first year of separation from active duty (which is coming up soon on April 30, 2016) to fall within the presumptive period. Might it still be prudent to have a VA attorney and separate medical examiner actually properly measure the left hip range of motion before April 30, 2016? Right now it could look like I’m totally fine with no documented hip ROM issue (if the C&P examiner just put that my hip ROM is normal). Thus, I’m thinking ahead to appeal... Would it be good if I had an independent examiner who had measured left hip ROM BEFORE the one year had elapsed to prove that I really had ROM limitations within the presumptive period?

I’m probably over thinking this but…

Would it not be necessary to go to the trouble/expense at this point?

 Can I allow time to elapse beyond the 1 year post separation mark, and simply point to the fact that the examiner didn’t measure the left hip ROM accurately. I do in fact have a well-documented issue with a bulging disc in the back, and left hip piriformis syndrome, and now left leg/hip IT band syndrome recently diagnosed (along with various physical therapist's notations of an off-kilter gait). In light of the C&P examiner’s inadequate exam, and my extensive medical record to document my relate issue, would the left hip measurements probably in fact carry the same “weight” if they are to be collected months from now (with left hip ROM being a logical continuation of the limitation of reduced left hip ROM, which I have been experiencing, albeit not having been properly documented on the C&P exam)?

Help much appreciated.

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