Range of motion

[SPO]

My doc filled out an arthritis dbq for me linking it to an already serviced connected condition.  However, he checked "no" for range of motion issues, but he never did a range of motion exam. I do have range of motion issues in multiple joints, especially during a flare up. I don't know if he checked no because he couldn't say yes or what.  Is this going to be a problem going forward, especially if a C&P examiner sees it?

[broncovet]

There are 2 ways to "correct" errors on your medical report:

1.  Go back to that doc, and ask him to correct the errors and amend your exam:

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 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 appealwithin 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 requestersdesiring 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, theSecretary 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)) ( 38 U.S.C. 501)

 

[ 47 FR 16324, Apr. 16, 1982]

 

2.  Get another doc (ie an IMO) to refute that doctors mistake.  This will likely cost you money.  

[SPO]

This was a private doctor and it hasn't been submitted to the VA yet. Would it be acceptable if there was a note that said "not tested" under the block where he checked no?  I would get the doctor who signed the form to do it.

[broncovet]

Well, if I had HIRED a private doc, then you can bet I would be knocking on his door asking "why" it was not tested, that you need that info for benefits.  You need to take a proactive role in your benefits, and, if you dont follow up on this, who should you blame if you dont get a good result?  If the IMO (private doc) report was unacceptable for VA purposes, you should contact them and explain EXACTLY what you need:

1.  CV of the doc, showing his expertise in giving this opinion.

2.  The doc needs to state he "reviewed your records" so you have to make those available to him.  

3.  The doc needs to state the nexus in a format VA accepts.  Unacceptable examples:  Your condition "may" be related to service.  Your condition "could be" related to service.  

Acceptable to VA:  Your condition is "at least as likely as not" related to (event) in service.  Then, he needs to state why he said so. (medical rationale.)

4.  The doc should sign it.  

     If any of the above are erroneous, or missing, or ambigious, then the IMO wont be worth anything to you.  If you have to pay more to get it right, then do so, but getting it wrong wont help you, it will hurt you more.  

     The doc may not be doing this to "hurt" you, chances are good he is unfamiliar with VA policies.  He may have also not realized you are willing to pay for the ROM tests...these could be done by a physical therapist and "signed off" by a doctor who has confidence in the physical therapist.  ALL of my ROMS are done by PT's, neither my surgeon, nor my PCP did any ROM tests..

     I have a family member who is a MD.  She has people she trusts, and has no problem "signing off" on them.  As an example, the doc will often order some kind of a shot..almost always administered by the nurse, not the doc.  So the doc is often not even in the room when the shot is given.  Still, he signs off that the shot was given.  How?  Well because he trusts the nurse.  My family member who is a doc, "signs off" on the PA because she trusts the PA's judgement.  She knows she is ultimately responsible, but you cant really be an effective doctor if you do not trust your nurses, PA's, NP's, and the like.  In a similar way, the nurse will often delagate some jobs to the Nursing Assistant, at least to the extent which is not prohibited.  

Last time they drew blood from me (I had 3 different nurses try), I wish they would have given me the Phlebotomist.  The Phlebotomist(s) often do dozens and dozens of draw blood per day, while a nurse or doc, may do them only rarely.  So the phlebotomist is often very, very good at drawing blood.  (A person can become a phlebotomist is just a few months training).  A nurse or a doctor takes much much more training and schooling.  Still, there is no doubt in my mind, I want a phlebotomist to draw blood or even start an IV.  They get blood from me easily every time, while the nurses have trouble.  

[SPO]

The doc who did it is a Dermatologist (which are capable of diagnosing psoriatic arthritis), so i don't know that his specialty would be the most credible when it comes to ROM.  He did make a statement that "it is more likely than not that the patient's psoriatic arthritis is caused by/connected to by already service connected psoriasis."  He has been the only treating physician for this condition since onset.  I did not pay above and beyond my normal visit fees for him to fill DBQ out for me.  I just don't want to get burned on a C&P because he check no in 1 block.  I will follow up with him to see if he will sign off on a PT to do ROM though.

Edited December 4, 2018 by SPO

[broncovet]

Smart idea.  Get all the evidence you need, and they shouldnt call for a c and p exam.  They may still do so anyway, but that is a different issue.  I agree not to set your self up to a negative c and p exam, reminding you that your c and p examiner is also supposed to "review your records".  So the examiner may interpret this exam that you dont have loss of ROM.  

Dont be afraid to pay a little extra for that need ROM test.  Its still bound to be cheaper than a 2000 dollar IMO.  

Edited December 4, 2018 by broncovet

[SPO]

The doc said no to using and outside pt, but will remove the “no” and just leave it blank.  I guess this is the best I’ll get.  It at least has his service connection statement and a diagnosis.