2.09 Adequacy Of Examination And Hospital Reports

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M21-1-6 Rating Board Procedure

2.09 ADEQUACY OF EXAMINATION AND HOSPITAL REPORTS

a. VA Examinations. If a VA report of examination (including VA Form 21-2680, "Examination of Housebound Status or Permanent Need for Regular Aid and Attendance") is inadequate in any essential particular, the reasons for inadequacy will be outlined and the report returned through channels for a corrected supplementary report or for reexamination. See also chapter 1.

b. VA Hospitalization. In the event a VA report of hospitalization is found to be inadequate in the following types of cases, request the original clinical records, including nurses' and doctors' orders:

(1) Cases involving injury or aggravation of injury or death as the result of hospitalization, medical or surgical treatment or examination.

(2) Death cases if the veteran, who died from a nonservice-connected cause, had a service-connected neuropsychiatric disability that reasonably may have impeded, obstructed, or otherwise interfered with treatment for the condition that caused death, but the report does not clarify this issue.

c. Non-VA Facilities. If a report from a State, county, municipal, contract, or recognized private institution or hospital is inadequate in any essential particular, request clarification, and if a satisfactory corrected report cannot be obtained within a reasonable period of time, authorize a VA examination.