Jump to content

Announcements



  • veteranscrisisline-badge-chat-1.gif

  • Advertisemnt

  • 14 Questions about VA Disability Compensation Benefits Claims

    questions-001@3x.png

    When a Veteran starts considering whether or not to file a VA Disability Claim, there are a lot of questions that he or she tends to ask. Over the last 10 years, the following are the 14 most common basic questions I am asked about ...
    Continue Reading
     
  • Ads

  • Most Common VA Disabilities Claimed for Compensation:   

    tinnitus-005.pngptsd-005.pnglumbosacral-005.pngscars-005.pnglimitation-flexion-knee-005.pngdiabetes-005.pnglimitation-motion-ankle-005.pngparalysis-005.pngdegenerative-arthitis-spine-005.pngtbi-traumatic-brain-injury-005.png

  • Advertisemnt

  • VA Watchdog

  • Advertisemnt

  • Ads

  • Can a 100 percent Disabled Veteran Work and Earn an Income?

    employment 2.jpeg

    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

  • Ads

  • Fundraising-001.jpegFund HadIt.com Veteran to Veteran LLC

    HadIt.com Veteran to Veteran Fundraiser
    Revenues are down, costs are up and I need your help. Financial gifts are always appreciated but never required. If HadIt.com has helped you and you can give back a little it is appreciated Give here https://community.hadit.com/donate/make-donation/

    Give a financial gift to help with the upkeep of HadIt.com. HadIt.com is NOT a non profit. Gifts are not tax deductible, they are just gifts. 

  • Donation Box

    Please donate to support the community.
    We appreciate all donations!
  • Our picks

    • How to get your questions answered...


      All VA Claims questions should be posted on our forums. Read the forums without registering, to post you must register it’s free. Register for a free account.

      Tips on posting on the forums.

      Post a clear title like ‘Need help preparing PTSD claim’ or “VA med center won’t schedule my surgery” instead of ‘I have a question’.


      Knowledgable people who don’t have time to read all posts may skip yours if your need isn’t clear in the title. I don’t read all posts every login and will gravitate towards those I have more info on.


      Use paragraphs instead of one huge, rambling introduction or story. Again – You want to make it easy for others to help. If your question is buried in a monster paragraph there are fewer who will investigate to dig it out.


      Leading to:

      Post clear questions and then give background info on them.

      Examples:

      A. I was previously denied for apnea – Should I refile a claim?


      I was diagnosed with apnea in service and received a CPAP machine but claim was denied in 2008. Should I refile?



      B. I may have PTSD- how can I be sure?

      I was involved in traumatic incident on base in 1974 and have had nightmares ever since, but I did not go to mental health while enlisted. How can I get help?



      This gives members a starting point to ask clarifying questions like “Can you post the Reasons for Denial from your claim?” etc.

      Note:

      Your firsts posts on the board may be delayed before they show up, as they are reviewed, this process does not take long and the review requirement will be removed usually by the 6th post, though we reserve the right to keep anyone on moderator preview.

      This process allows us to remove spam and other junk posts before they hit the board. We want to keep the focus on VA Claims and this helps us do that.
      • 2 replies
    • Exams that were being sent strictly to contractors before, due to VAMCs not being open, are starting to be routed back to VAMCs. This is going forward from last Friday- not sure if prior scheduled exams will be re-created for VAMC vs vendor.
      • 7 replies
    • Mere speculation in your VA C and P exam

      M21-1, Part III, Subpart iv, Chapter 3, Section D – Examination Reports III.iv.3.D.2.r. Examiner Statements that an Opinion Would be Speculative Pay careful attention to any conclusion by the examiner that an opinion could not be provided without resorting to mere speculation (or any similar language to that effect). VA may only accept a medical examiner’s … Continue reading
      • 0 replies
    • A favor please - just changed servers so if you have a moment...
      A favor please - just changed servers so if you have a moment go to https://www.hadit.com I'd like to see how the server handles a lot of traffic. So if you have a moment click the link and i can see how things are going on the back end.
      • 11 replies
    • It's time to ask for help from the community. If you can help with a gift it would be very appreciated.

      Fund HadIt.com Veteran to Veteran LLC


      Give a financial gift to help with the upkeep of HadIt.com. HadIt.com is NOT a non profit. Gifts are not tax deductible, they are just gifts. 
      • 11 replies
  • Advertisemnt

  • 0
Sign in to follow this  
hemipepsis5p

Incorrect mental health info entered into records by RN

Question

Hello,

So recently I called the VA to make a mental health appointment. Up to now, I had been using a private psychiatrist, but now I'm dirt poor so I have to rely on the VA. Well, I called them up to make the appointment and the lady (turned out to be an RN) asked me, "Okay, so, any thoughts of suicide, any self-harm, stuff like that?" I took that to mean recently, as in, am I in a dire state right now. I answered "no" because I haven't had any of that going on in the last few months. The records I looked at state that she asked that to determine how soon I should be seen. It was then signed off on by a psychologist. So I was right about the whole "dire state" thing, right? When I read my records however, the entry said,

"Have you ever had thoughts of suicide? No." 
"Have you ever engaged in self-harm? No."

That is not what I was asked! Both of those are completely wrong! Those questions were not asked! Instead, her question was phrased ambiguously. I also needed transportation to the VA, and she said "We don't do that but maybe I can get you some help" and gave me two phone numbers, and nobody answered either one. I then googled it and found the transportation person for my local VA (different phone number) and had a ride scheduled within 10 seconds. Can I include this as evidence of her incompetence?  I'm about to submit my claim for a decision (but not until this is taken care of). How should I handle this? Should I put in a statement in support of claim mentioning this?

- Phil

Edited by hemipepsis5p
more details

Share this post


Link to post
Share on other sites

5 answers to this question

Recommended Posts

  • 0

To correct errors in your records, use the regulation posted below.  You "may" be able to simply speak to the nurse about the error and she may correct pronto.  

Or, she could make it more difficult.  If you are unable to resolve this error, remember, the VA has to consider "all the records".  This means if several docs have already documented SI, you dont have to have it documented with EACH doctor.  If you go to the eye doc, you probably dont need to mention your SI.  

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 theindividual 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 anyrecord 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 requeststo 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 therequest 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 disputedrecord has been disclosed. ( 5 U.S.C. 552a(d)(4)) ( 38 U.S.C. 501)

[ 47 FR 16324, Apr. 16, 1982]

Share this post


Link to post
Share on other sites
  • 0

"I'm about to submit my claim for a decision (but not until this is taken care of). How should I han..."

Have you formally filed a claim yet and if so was this a  formal C & P exam?

Share this post


Link to post
Share on other sites
  • 0

I have formally filed a claim, and no this wasn't from a C&P exam, it was from my very first phone call with my local VA to set up a mental health screening. The notes do however contradict the notes in my C&P exam, which has me worried.

Share this post


Link to post
Share on other sites
  • 0

Please post a redacted C&P so we can better know how you were identified by the doctor.  A nurse might not mark you as a SI risk while the C&P doctor has a greater responsibility to get it right.  There is a question on the DBQ (form the doctor fills out) that specifically asks your risk of suicide.

Share this post


Link to post
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.

Guest
Answer this question...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

Sign in to follow this  

  • Similar Content

    • By damnitface77
      For Starters, I want to thank anyone who takes the time to read this and give me a little perspective. I just got my final C&P results after a series of claims. Currently I am 94% combined rating if I include my Sleep apnea claim (The Dr. wrote it was medically neccesary to use the CPAP, so I do expect the 50%. This C&P below was conducted to separate my anxiety disorder from my TBI disorder. Currently I have a 70% rating for Anxiety with residuals of TBI. I was wondering if anyone could read this and tell me if they think I can expect a separate rating for TBI memory loss based on the Dr's opinion stating that my issue is 80% anxiety and 20% TBI (see note 2b below). If I can get at least a 10% for TBI in addition to the 70% for anxiety, It should push me over the threshhold of 100% schedular. The only edits I made to this was to remove names.  Again, thank you for your time and expertise
      70% Anxiety (Trauma with TBI residuals)
      50% Sleep Apnea
      20% Degenerative Disc Disease
      20% Upper Neuropathy Right / 20% Upper Neuropathy Left
      10% Lower Radiculopathy Right / 10% Lower Radiculopathy Left
      0% TBI Migraines
      LOCAL TITLE: COMP AND PEN NOTE
      STANDARD TITLE: C & P EXAMINATION NOTE
      DATE OF NOTE: JAN 28, 2019@14:30 ENTRY DATE: JAN 30, 2019@11:11:26
      AUTHOR: *********** E EXP COSIGNER: URGENCY: STATUS: COMPLETED
      Mental Disorders
      (other than PTSD and Eating Disorders)
      Disability Benefits Questionnaire Name of patient/Veteran: *****
      Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination
      Request?
      [X] Yes [ ] No
      SECTION I: ----------
      1. Diagnosis
      ------------
      a. Does the Veteran now have or has he/she ever been diagnosed with a mental
      disorder(s)? [X] Yes [ ] No
      ICD code: 300.00
      If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses:
      Mental Disorder Diagnosis #1: Unspecifed Anxiety disorder, chronic, severe
      disorder.
      ICD code: 300.00 Comments, if any:
      Vet had been seen initially on 2/11/18 for Mental Health C+P exam done
      by Dr. *****(which proposed "Anxiety disorder, NOS" then, while f/u
      C+P exam on 2/16/14 had proposed Other specified trauma and stressor related disorder(as vet had been in IED blast in 2006 - see Mental Disorder diagnosis #2 below.
      Unspecified anxiety disorder is synonymous with Neurosis - which vet is
      already 70% SC for, in combination with residuals of TBI apparently). I
      am therefore not intending to change his Neurosis condition now, but Unspecified anxiety disorder is most accurate diagnosis consistent with DSM-V, as I see it now.
      Mental Disorder Diagnosis #2: Cognitive disorder due to Closed Head
      iInjury(CHI), due to 6/1/2006 "double-attacked anti-tank mine" IED blast.
      ICD code: 294.9 Comments, if any:
      Vet was in 2nd Iraq combat deployment - out of 3 tours he served there -
      when 6/1/06 IED hit his heavy equipment vehicle(which vet had referred to as 'palitizing loading system').
      b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Vet is already 0% SC for
      migraine headaches.
      Comments, if any:
      Vet is already SC for migraine headaches. Vet is already 20% SC for Intervertebral DIsc Syndrome, 20% SC for Paralysis of musculospiral nerve(x2), 10% SC fo paralysis of sciatic nerve(x2).
      Vet also apparently had a 2/15/18 sleep study done that indicated a mild
      sleep apnea condition.
      2. Differentiation of symptoms
      ------------------------------
      a. Does the Veteran have more than one mental disorder diagnosed?
      [X] Yes [ ] No
      b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
      [X] Yes [ ] No [ ] Not applicable (N/A)
      If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses Symptoms(i.e., anxiety, sleep problmes) are due to Unspecified
      anxiety disorder, while symptoms(memory problems, headaches) are due
      to Cognitive disorder due to CHI.
      c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [X] Yes [ ] No [ ] Not shown in records reviewed
      d. Is it possible to differentiate what symptom(s) is/are attributable to TBI
      and any non-TBI mental health diagnosis? [X] Yes [ ] No [ ] Not applicable (N/A)
      If yes, list which symptoms are attributable to TBI and which symptoms
      are attributable to a non-TBI mental health diagnosis see 2b above.
      3. Occupational and social impairment -------------------------------------
      a. Which of the following best summarizes the Veteran's level of
      occupational
      and social impairment with regards to all mental diagnoses? (Check only one)
      [X] Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or
      mood
      b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [X] Yes [ ] No [ ] Not Applicable (N/A)
      If yes, list which occupational and social impairment is attributable to each diagnosis
      About 80% of vet's current occupational and social impairment is due
      to Unspecified anxiety disorder while about 20% is due to Cognitive disorder due to CHI.
      c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [X] Yes [ ] No [ ] Not Applicable (N/A)
      If yes, list which impairment is attributable to TBI and which is attributable to any non-TBI mental health diagnosis see 3b above.
      SECTION II:
      ----------- Clinical Findings: ------------------
      1. Evidence Review
      ------------------
      Evidence reviewed (check all that apply):
      [X] VA e-folder
      [X] CPRS
      [X] Other (please identify other evidence reviewed):
      Vet broiught a 4 page typed letter 1/12/19 done by himself describing
      in detail his current ongoing issues("I did not want to forget to tell
      you something important"), and vet admits it took him severalhours to
      complete(and which he kept revising many times). He brought a 2 page
      letter dated 1/27/19 done by his wife ******, a 2 page typed letter dated
      1/17/19 done by mother ********, and a 1 page typed letter dated
      1/27/19 done by vet's friend/combat comrade(served together in Iraq)
      named *******, and all 4 letter were reviewed by me.
      Evidence Comments:
      CPRS was reviewed by me and included my(***** MD) 12/5 18 Review TBI C+P exam report, as well as 5/16/14 C+P exam report done by Dr *****(sa
      well
      as Initial 2/18/11 MH C+P exam aslo done by Dr. ******.
      VBMS was reviewed by me and included vet's Army DD-214 signed b *****
      which included MOS(88M30) Mortor Vehicle Operator,as well as E-6 discharge
      rank. His medals included CAB - among others, and he had Iraq combat dates
      of 1/03 - 7/03, 8/05 - 8/06, and 3/08 - 6/09 - for his 3 seperate Iraq combat tours.
      2. History
      ----------
      a. Relevant Social/Marital/Family history (pre-military, military, and
      post-military):
      Vet is married ****(and they have 2 sons(around ages 5 and nearly 7).
      b. Relevant Occupational and Educational history (pre-military, military, and
      post-military): Vet has been working in his current Passport Agency job since 2015(was at an administrative clerk(for a different agency) before that.
      c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military,
      and post-military):
      Vet has been on sertraline 150mg since 9/10/18 - it takes the "edge" off
      my problems, but he apparently has been having some sexual side effects(delayed ejaculation) related to that .
      d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
      Vet has had no legal problems(and no jail time) since the 5/14/16 C+P exam report date.
      e. Relevant Substance abuse history (pre-military, military, and post-military):
      Vet has had no alcohol misuse disorder problems sicne 5/16/14. He has used no street drugs since 16/14.
      f. Other, if any:
      No response provided.
      3. Symptoms
      -----------
      For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:
      [X] Anxiety
      [X] Suspiciousness
      [X] Panic attacks that occur weekly or less often
      [X] Chronic sleep impairment
      [X] Mild memory loss, such as forgetting names, directions or recent
      events
      [X] Impairment of short- and long-term memory, for example, retention of
      only highly learned material, while forgetting to complete tasks
      [X] Disturbances of motivation and mood
      [X] Difficulty in establishing and maintaining effective work and social
      relationships
      [X] Difficulty in adapting to stressful circumstances, including work or
      a
      worklike setting
      [X] Obsessional rituals which interfere with routine activities
      4. Behavioral observations
      --------------------------
      Vet was totally genuine at the 1/28/19 Review Mental Health C+P exam.
      5. Other symptoms
      -----------------
      Does the Veteran have any other symptoms attributable to mental disorders that are not listed above?
      [X] Yes [ ] No
      If yes, describe:
      Vet admits to having anger difficulties, 'spacing out' at times, and
      general feeling of being confused/overwhelmed. He reports having lost
      his social "filter" abilities. He reports previously having been very
      "easygoing" prior to the military.
      Vet still gets nervous if seeing sandbags lying on the side of the road -
      left by construction crew(as that is what he looked for over in Iraq as being a potential IED.)
      He has to reorganize plates/trays a certain way, either at home or when leaving a restaurant, respectively.
      He denies having any suicidal thoughts("No, I'm addicted to life, I love
      breathing".).
      6. Competency
      -------------
      Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No
      7. Remarks (including any testing results), if any: ---------------------------------------------------
      Vet owns a pistol. He does not hunt - only tried it once, but did not get anything then.
      He denied having any current active suicidal or homicidal ideation.
       
    • By Navy4life
      Hi there!  Long time member here but been MIA for awhile.  Life has been busy and I have been dealing with health issues.  Long story short, I went through a battery of tests to find out what is wrong with me.  I did an ANA-TITER test, and it was positive for an auto immune disease.   Was referred to the RA doctor for further testing to see if I had lupus.  The RA doctor did blood tests and determined I don't have lupus.  We did additionally physical exam at the VA back in May and he determined I had Fibromyalgia and diagnosed me with it.  We discussed that my Fibromyalgia co-exists with PTSD/MST and IBS.  We also discussed that Fibromyalgia can be secondary to my already service-connected PTSD/MST or even maybe my IBS.  I discussed this with my representative and we decided to file a claim for Fibromyalgia (non-service connected disability) to an already service-connected disability.  Either PTSD/MST or IBS and we asked that they evaluate either causation or aggravation.
      We filed in July and I had my C&P exam in September.  The examiner was asked by the rater to give his medical opinion as to the Fibro being secondary to my PTSD/MST.  The rater did not ask if it was possible to be secondary to my IBS like we requested.  The examiner did a C&P DBQ for Fibro and that was positive.  I do have Fibro, that isn't the issue.  The medical opinion is what was disturbing.  I was with the examiner for less than 5 minutes.  He stated he physically examined me when he did not and he seemed very unknowledgeable about Fibro/PTSD-MST/IBS as co-existing and determining either causation or aggravation.  Of course the medical opinion stated, "less likely than not".  I was floored, so I went to work for my claim.
      I contacted my RA doctor and we talked with my representative on the phone as well.  By the end of the call he was confident enough to link my PTSD/MST as aggravation to my Fibromyalgia.  He wrote a one/two paragraph letter on my behalf.  We sent that to the rater.  Then I spoke to my MH provider last week and she too wrote me a very good NEXUS letter.  That was sent to the rater yesterday.  Both my doctor's are at the VA and both stepped out on a limb for me.  I am hoping their medical opinions outweigh the negative C&P medical opinion.
      I am attaching the C&P exams (redacted), the two medical opinions (redacted) - I am hoping I am successful because this will make me 100% scheduler.  I am currently 94% overall rated.
      C&P _Redacted.pdf
      nexus 2_Redacted.pdf
      redacted.pdf
      redacted2.pdf
    • By CaliBay
      Hello everyone,
      It has been a while but I finally received my C&P examination for mental health.  Currently am 50% for Major Depression, seeking 70%.  I went to my examination in stained sweats, faded shirt, flip flops, unshaven, and hair frizzy and not brushed.  For some reason, I believe my C&P examiner was wishing I did not come so she could go to lunch early based on her reaction to my arrival and her BSing with the receptionist prior.  Anyway, I feel angry after reading her assessment and would like to know what you all think.  I think she checked the box for 30% which is a decrease but all the symptoms are 70% looking.  It feels really bad she is trying to make me out to be a liar when she doesn't know how I really feel.  I have been suicidal, I have made attempts, I have researched the best methods, made plans, etc.  The closest I have come is purchasing roper, tying it in a noose, and testing out a bar at work to see if it could support me in hanging myself.  But I have really been feeling like crap and feel I have to fight really hard to not let my thoughts become the truth.   All things she did not ask.  What do you think will happen based on the below exam results?  I thank you for your time and responses.
       
      CaliBay
       
      Mental Disorders (other than PTSD and Eating Disorders)
      Disability Benefits Questionnaire
       
      Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request?
      [X] Yes [ ] No
      SECTION I:
      - - - - - - - - - -
      1. Diagnosis
      - - - - - - - - - - - -
      a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder?
       [X] Yes [ ] No
      ICD code: F33.2
      If the Veteran currently has one or more mental disorders that conform to
      DSM-5 criteria, provide all diagnoses:
      Mental Disorder Diagnosis #1: Major Depressive Disorder, severe, recurrent
      ICD code: F33.2
      Mental Disorder Diagnosis #2: Generalized Anxiety Disorder, with panic attacks
      ICD code: F41.1
      b. Medical diagnoses relevant to the understanding or management of the
      Mental Health Disorder (to include TBI): severe sleep apnea
      2. Differentiation of symptoms
      - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
      a. Does the Veteran have more than one mental disorder diagnosed?
      [X] Yes [ ] No
      b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
      [X] Yes [ ] No [ ] Not applicable (N/A)
      If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses
      Depression - depressed mood, not feeling pain, poor motivation, nightmares, few friends, feel worthless and helpless.
      Anxiety: doesn't like to leave his house, uncomfortable in crowds, some paranoia shakes
      c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
      [ ] Yes [X] No [ ] Not shown in records reviewed
      3. Occupational and social impairment
      - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
      a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one)
      [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation
      b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder?
      [ ] Yes [X] No [ ] No other mental disorder has been diagnosed
      If no, provide a reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis:
      symptoms of GAD and MDD overlap and it is nearly impossible to differentiate between disorders.
      c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI?
       [ ] Yes [ ] No [X] No diagnosis of TBI
      SECTION II:
      - - - - - - - - - - -
      Clinical Findings:
      - - - - - - - - - - - - - - - - - -
      1. Evidence Review
      - - - - - - - - - - - - - - - - - -
      Evidence reviewed (check all that apply):
      [X] VA e-folder (VBMS or Virtual VA)
      [X] CPRS
      2. History
      - - - - - - - - - -
      a. Relevant Social/Marital/Family history (pre-military, military, and post-military):
      The veteran has been married for 25 years, and they have 4 children ages 17, 12, and 7. His father lives at their home, but he is self-sufficient and assists caring for the children. His spouse works at Kohls.
      b. Relevant Occupational and Educational history (pre-military, military, and post-military):
      He works for the Federal Government as Transportation Specialist at the GS-11 pay grade.  He stated that his supervisor has made a verbal accommodation for his mental disabilities to let him come and go as he pleases including arriving late and leaving early for work for appointments.  He states he does not know exactly what he does at work but feels like a government worker that is unqualified for his position and got lucky to obtain his current job.  He states he answers email correspondence all day and surfs the Internet.  He stated that his duties are not really defined and much of his job requires little effort mentally or physically.  He creates spreadsheets in Excel and analyzes financial data for travel.  He works from 8:00 am to 5:00 pm.  He stated that he has used his all of his vacation and sick time because of his disability.  He was out of work on FMLA for three months to receive mental health care and has returned in May 2017 with difficulty adjusting.
      c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):
      He stated that he was feeling better during for two months in a 12-month period.  Since he returned to work, his depression has increased and has frequent panic on a daily basis. He stated that he feels paranoid that someone is out to get him. He feels like he is worthless at work even though his managers have never told him his performance is poor.
      He does not recall periods of remission and stated that he only remembers all the bad things that have happened to him.  He uses a CPAP machine but states he rips it off his face every night due to nightmares.  He has always had nightmares of when his daughter passed away and escorting human remains off of military cargo planes.  He estimates waking up every hour to check on his children to see if they are still alive.  He self-admitted to a Mental Health Hospital for 3 months. He was suicidal and very depressed.  He has not seen a Therapist but he has spoken to his Psychiatrist.
      Nightmares: never decreased, nightly or every other night. His nightmares are of the same theme.
      No exercise
      Medical records review:
      DBQ from private provider
      Statement from veteran
      Treatment records from Private Hospital
      Treatment records from Mental Hospital
      These records are consistent with a diagnosis of Major Depressive Disorder, and Generalized Anxiety Disorder. Many medications have been
      tried. He is at low risk of suicide at this point.
      Current Medication:
      Wellbutrin
      Abilify
      Prozac
      d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
      None
      e. Relevant Substance abuse history (pre-military, military, and post-military):
      He drinks occasionally and states he is a “light weight” in consuming alcoholic beverages.  Sometimes he inhales CO2 from whip cream to get a temporary high.
      f. Other, if any:
      No response provided.
      3. Symptoms
      - - - - - - - - - - -
      For VA rating purposes, check all symptoms that actively apply to the
      Veteran's diagnoses:
      [X] Depressed mood
      [X] Anxiety
      [X] Chronic sleep impairment
      [X] Flattened affect
      [X] Disturbances of motivation and mood
      [X] Suicidal ideation
      4. Behavioral observations
      - - - - - - - - - - - - - - - - - - - - - - - - - -
      No response provided.
      5. Other symptoms
      - - - - - - - - - - - - - - - - -
      Does the Veteran have any other symptoms attributable to mental disorders that are not listed above?
      [ ] Yes [X] No
      6. Competency
      - - - - - - - - - - - - -
      Is the Veteran capable of managing his or her financial affairs?
      [X] Yes [ ] No
      7. Remarks (including any testing results), if any:
      - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
      This 45-year-old veteran still struggles with depression and anxiety. I cannot diagnose him with PTSD because it appears to be secondary to MDD.  He has not seeked therapy other than admitting himself to a Mental Health Facility.  The veteran has been advised to get help for his symptoms and he has not complied.  There doesn't appear to be any changes in his mental health status. The fact that this veteran continues to work without incident suggests that he may be functioning better than what he is showing.  I recommend that this veteran receives intensive therapy and be re-evaluated after a year of consistent treatment.
    • By Rich p
      Voiceless Veterans 
      We arrive, angry, confused, hurt, untrusting, extremely defensive, with a strong tendency for coming off "rudely direct" and somewhat scatter brained. By the time, we finish speaking, we've likely already "pissed off" our intended receivers. Then, we receive our threat of VA police intervention, unless we comply, and speak with respect. Who are we?
      We are the "voiceless members" of the "highest VA risk group" known as "mentally challenged veterans". We perhaps impact the high rate of suicide, more than any other group, found among veterans, past and present. Everyone is concerned for our well fair and rightfully so. Yet.....
      We all witnessed a veteran act out and take the lives of five Dallas police officers. We all read about the veteran taking his life the day before thanksgivings in Tennessee. We watched again as a veteran drove his car into a crowd in New Jersey. These were all members of my group. They each acted out in horrible ways. They acted with purpose. Each were previously rejected help, by the VA!
      Replace the acronym "PTSD" with "HULK" and everyone will understand us better. PTSD, as in my case, has not diminished intelligence, it clouds my use of it. The CCVA, addressed the plight of the mentally challenged veteran in Clemons v Shinseki, 2009, emphasizing the inability of a mentally challenged veteran, to narrow their own claims, before a more knowledgeable and experienced VA employee.
      We would have hoped a ruling from the highest VA court, would have produced a wide range of assistance and protections for us mentally challenged veterans. The court declared it to be enough that a veteran apply with a mental health claim to trigger the special attention required under Clemens. What good are CCVA decisions when VBA directors have no responsibility to follow them, at least that's the way the Tennessee region applies it. 
      Rulings are muted, as veterans in my group have no way to address them. We are threatened with police action, by the VA, defenseless before the DOJ, ignored by politicians, called crazy by caretakers, and all is well, once again, in the life of a stressed out government employee. Our lives are ripped apart, stress increased beyond belief, we end up living in a shed for years, waiting on the VA to respond.
      We once believed ourselves more than just a veteran, we thought we answered the call for something, more than that. We stood the ground assigned and completed our small part in the defense of our Nation. We stood for all of our nations people. We stood for our own constitutionally protected rights and believed ourselves protecting them. 
      From one Generation to the next, less than 3% of Americans have served their country and even less during time of war, is it to much to ask for a voice? Is it to much to ask that we not be required to sacrifice everything we had worked so hard and so long for. The wars we fight are not in your neighborhood. If you let the 2% keep getting treated this way, the next one will be. I'm a Vet, too, has become an excuse, not the badge of honor it was intended to be. We stood up when you called and we came home different. Will you not stand up for what our families are loosing, because we chose to defend you?
      To quote the late Paul Harvey " Now you have, the rest of the story."
       
      Stand on Clemons and force the VA to address all of the material facts. Now read Bevins and six unknown narcotics agents and the new VA accountability law. This will force the VA to address the whole disability picture the first time they touch the record or they fail Clemons. Do not pursue the adjudicator, pursue the signing authority as they have a written obligation to ensure the law has been followed. The new accountability law is specifically positioned to tag these individuals for failing their signing obligation, therefore failing Clemons. My claim went from 50% to 100% based on the same medical evidence. No new exams, no bull, claim Clemons and point to your Disagreement, then let them assume liability for failing Clemons. 
    • By Andyman73
      I have a secret to tell.  I am afraid of falling down the stairs.  A few weeks ago, I was going down the steps at home, carrying my 13 pounder aka 5 month old foster babygirl., and I felt a near blinding pain in my R foot, which made me nearly finish my trip down the stairs in stunt person style.
      So, here's the problem, ever since then, every time I am faced with going down any flight of stairs, I keep seeing the stairs I fell down during boot camp.  Is this something to be concerned with?  It sure bugs the crap out of me.  I was always leary of stairs ever since that boot camp fall...but not like this...especially now since I have various foot, ankle, and knee issues, both SC and non-SC.
      I didn't want to even mention it here, but I keep hearing a voice in my head telling me that I need to speak up, so someone can tell me that I'm not crazy, or...at least, not as crazy as I think I am.  Should I tell my VA MH at my next therapy session?  Is this something not even worth mentioning?  Now I feel so dumb and childish for having mentioned it...
  • Ads

  • Our picks

    • How to get your questions answered...


      All VA Claims questions should be posted on our forums. Read the forums without registering, to post you must register it’s free. Register for a free account.

      Tips on posting on the forums.

      Post a clear title like ‘Need help preparing PTSD claim’ or “VA med center won’t schedule my surgery” instead of ‘I have a question’.


      Knowledgable people who don’t have time to read all posts may skip yours if your need isn’t clear in the title. I don’t read all posts every login and will gravitate towards those I have more info on.


      Use paragraphs instead of one huge, rambling introduction or story. Again – You want to make it easy for others to help. If your question is buried in a monster paragraph there are fewer who will investigate to dig it out.


      Leading to:

      Post clear questions and then give background info on them.

      Examples:

      A. I was previously denied for apnea – Should I refile a claim?


      I was diagnosed with apnea in service and received a CPAP machine but claim was denied in 2008. Should I refile?



      B. I may have PTSD- how can I be sure?

      I was involved in traumatic incident on base in 1974 and have had nightmares ever since, but I did not go to mental health while enlisted. How can I get help?



      This gives members a starting point to ask clarifying questions like “Can you post the Reasons for Denial from your claim?” etc.

      Note:

      Your firsts posts on the board may be delayed before they show up, as they are reviewed, this process does not take long and the review requirement will be removed usually by the 6th post, though we reserve the right to keep anyone on moderator preview.

      This process allows us to remove spam and other junk posts before they hit the board. We want to keep the focus on VA Claims and this helps us do that.
      • 2 replies
    • Exams that were being sent strictly to contractors before, due to VAMCs not being open, are starting to be routed back to VAMCs. This is going forward from last Friday- not sure if prior scheduled exams will be re-created for VAMC vs vendor.
      • 7 replies
    • Mere speculation in your VA C and P exam

      M21-1, Part III, Subpart iv, Chapter 3, Section D – Examination Reports III.iv.3.D.2.r. Examiner Statements that an Opinion Would be Speculative Pay careful attention to any conclusion by the examiner that an opinion could not be provided without resorting to mere speculation (or any similar language to that effect). VA may only accept a medical examiner’s … Continue reading
      • 0 replies
    • A favor please - just changed servers so if you have a moment...
      A favor please - just changed servers so if you have a moment go to https://www.hadit.com I'd like to see how the server handles a lot of traffic. So if you have a moment click the link and i can see how things are going on the back end.
      • 11 replies
    • It's time to ask for help from the community. If you can help with a gift it would be very appreciated.

      Fund HadIt.com Veteran to Veteran LLC


      Give a financial gift to help with the upkeep of HadIt.com. HadIt.com is NOT a non profit. Gifts are not tax deductible, they are just gifts. 
      • 11 replies
  • Ads

  • Popular Contributors

  • Ad

  • Latest News
×
×
  • Create New...

Important Information

{terms] and Guidelines