Why do VA physicians & Therapist Miss Construe?

[Buck52]

Why do at times a VA MD or Therapist miss construes what we say during our visit with them and what can a veteran do about it   when he finds this in his MyhealthyVet Notes. 

what they talked about was NOT what they talked about?  &by this fabrication it can very well mess up a veterans claim and cause a reduction in benefit's

I hope the New Accountability Act will eliminate this ridiculous fabrication on the VA Dr's , Specialty Clinics ,Phyistrist and therapist a like.

Anyone ever had this happen to them? what did you do about it?

[Henrici]

Hey Buck 52

You are not alone, I check my medical notes and find inconsistencies all the time. Most are minor but some can give the wrong  impression especially if you have a claim going.

For me the most damaging is when the C&P examiners fudge the numbers like the degrees you able to bend forward in a back exam. They know what side their bread is butter on. The worst I had was an examiner say in her report that I stood up easily from my waiting room chair when called. In actuality I was exiting the restroom and never sat down. That is just a pure lie but how are you going to prove it. By the time you see the report there might not be time to do anything about it.

[broncovet]

You have a right to get errors on your medical records corrected:  At least sometimes, this isnt done maliciously against the VEt.  You should check your records, and make sure the doc accurately stated everything and get it amended if not.  38 CFR 3.1579 is as follows:  

 

Quote

 

§ 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 mayrequest 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; DeputySecretary, 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)) ( 

 

 

Edited July 21, 2017 by broncovet

[Buck52]

Well its not easy to fix...amends, a lot of it is just jebrish on the Dr's part  but some parts can be damaging to the veteran when they say his S.C. Disability has improved ...b/c the vet makes a statement that he has been sleeping better b/c of the PTSD AND ANXIETY Meds...without them no improvment.

Its like they think a veteran hearing has improved b/c he has hearing aids ,  without them he can't hear at all...but they test the veteran  hearing without  the use of hearing aids.

A veteran mention to me he got a proposal to reduce his benefits on his S.C. 50% HEARING LOSS B/C  he had went to one of his appointments and his battery in his aids was out  he took them off and the therapist mention to him about  his hearing aids he don't have them on  and the vet said he explain to her about the battery out...instead of the therapist helping him get some new batteries for his hearing aids  the therapist wrote up a bunch of lies about how his hearing had improved and not needing his hearing aids at today's session.  just flat out lied or misconstrued what the veteran mention.

(although batteries are free to Veterans with VA Hearing Aids)...some times their caught off off guard and  leave home without extra Batteries... I do it all the time.

I had that veteran to come to Hadit to get  his straighten out  I am not sure of his screen name? or if he actually got on hadit   I give him Ms T birds Hadit .com cards.

[broncovet]

I once met "Miss Construe".   She is married now, and has a Phd.  She is now called the VA, "spin Doctor".  

[Michigander]

I hear ya too @Buck52 and thank you @broncovet for posting the Amendment guidelines...it always gives me some backbone to read this stuff.  

I can't tell you how many times I read clinic notes that do not reflect anything close to what I said.  I notified my Primary via secure messaging how incorrect his notes were and that it could get me kicked off of the SSD that took me so long to fight and get.  I gave him great detail of our conversation to jog his memory of our office visit so he would amend his notes.  He replied to me via Secure Messaging that I did not say any of what I said I did and was very defensive.  What are we suppose to do...tell our physicians we are going to have to "record the entire clinic visit"??

From the same week I had to also see the cardiologist and reported the same problems I told the Primary about my severe increase in tachycardia episodes and calls for an ambulance to my home.  The cardiologist also did not reflect my increase in symptoms in my chart and infact stated I was improving!!

I sent a very strong message to that office too and demanded they amend my record and that I was going to patient advocacy if they did not do it ASAP.  From that clinic I received an apology message stating they did remember my conversation and did amend my notes.  I also received a phone call from the cardiologist apologizing.  

Now I am seeing the same issues with my mental health notes not reflecting what I said and contradicting even my handwritten notes from the packet I had to fill out for MH eval.  I brought that to there attention and nothing has changed over the past four weeks.  

I think I should call that VA hotline and make this a complaint....or is that not a good idea considering I will be filing a claim??

[broncovet]

Michigander:

    I think if you get your records amended (fixed), using the reg I posted, above, then your claim will have a much greater chance of suceeding than if you just call to complain.