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Documenting Your VA Claim – Examining your service medical records


Tbird
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Documenting Your VA Claim – Examining your service medical records

Documenting your claim, below is my system for going through service medical records.

First thing I do after receiving a service medical record is number each page when I get to the end I go back and add 1 of 100 and so on.

Second I then make a copy of my service medical records on a different color paper, yellow or buff something easy to read, but it will distinguish it from the original.

I then put my original away and work off the copy.

Now if you know the specific date it’s fairly easy to find.

If on the other hand you don’t know specifically or you had symptoms leading up to it. Well this may take some detective work and so Watson the game is afoot.

Let’s say it’s Irritable Bowel Syndrome (your diagnosis)I would start page by page from page 1, if the first thing I run across an entry that supports my claim for IBS is on page 10, I number it #1, I Bracket it in Red, and then on a separate piece of paper I start to compile my medical evidence index . So I would write Page 10 #1 and a brief summary of the evidence, do this as you go through all the your medical records and when you are finished you will have an index and easy way to find your evidence. Study your diagnosis symptoms look them up. Check common medications for your IBS (your diagnosis) and look for the symptoms noted in your evidence that seem to point to IBS (your diagnosis), if your doctor prescribes meds for IBS (your diagnosis), but doesn’t call it that make those a reference also.

38 CFR 3.1(D) Veteran means a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable. There’s more so make sure to read the regulations.

Were you diagnosed with an illness/injury in the service?

Is your current diagnosis and/or for that problem?

Was it documented in your service medical record?

Do you currently have a diagnosis that you think is related to your service?

Do you currently have a diagnosis, that though existed before service was aggravated by an illness/injury in service?

Can you link the aggravation to the illness/Injury in the service?

Information may be in your:

  • Service Medical Records
  • Hospital Records (Generally not included in Service Medical Records and may require on FOIA directly to that hospital.)
  • Performance Reports
  • After Action Reports
  • Journals
  • Letters Home
  • Conversations with buddies
  • Incident Reports you were involved in or witnessed

TIP: Also you can have a rubber stamp made with your full name social security number and address use this stamp at the bottom or top of each page you submit to the Veterans Affairs if it gets lost it will be easy to see which page goes to which claim.

Best Practices

Have a diagnosis from a doctor before applying for a claim, depending on what your claim is for the diagnosis may have to be from a Veterans Affairs doctor.

Request a copy of your service medical records. Requesting a copy of your Service Medical Records

If you have had a previous claim, request a copy of your claims folder. How to request a copy of your c-file (claims folder)

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