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Notes altered


Hoorah

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I have a question. My VA doctor wrote in my notes about a type of possible treatment about 6 months ago. I read the notes, and had an appointment the other day with this provider, and I brought up the notes about the treatment.  This doctor was absolute about not doing that treatment. Acting like no way. After the appointment I went online and checked myhealthevet notes. The notes were changed taking the treatment out, and was wrote that it is not available. So obvious!

I know that standard procedure is a provider will write an addendum on a note. I know a veteran can petition thru the Privacy FOIA Officer to have a doctor change the notes. The privacy officer said that if a doctor signs notes its final and they can't go back in an change notes. It was changed does anyone know, if or how a provider can go in and change the notes? Maybe an Admin edit or their Chief Medical (supervisor) change it?

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  • HadIt.com Elder

I love myhealthvet- Its not a Cfile but its a great papertrail and I download from it probably once a month (if I need to) and save as encrypted PDFs. My external drive could hold all the notes for probably about 50 of us going back forever, and I have it cloud uploaded into an encrypted space that I pay for (pretty cheap, actually). Should I die, all my VA treatment, scan of my Cfile (as it existed the last time I requested it), and a few pages of UN/PW for sites/social media (for deletion), VA log ins, Email addresses, and PH numbers are all there. I set it to respond directly to my wife's details so even if she forgets the UN/PW she can still get in. Morbid, I know, but still, its the same as  any of you that practice EDC (every day carry) or pack a GTH bag. Preparation is everything. You never want to have to use it. 

Thus endeth the lesson......go forth, sin no more......and also with you........

 

🙂

 

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Yes they can delete or change notes, I was skimming through my Problems List and realized that a diagnosis was gone...I have been getting treatments and on medication for a ailment for about 2 yrs and it's no longer in my VAMC Records, well the good thing for me, I made copies. And will continue to do so as long as I am getting treated at the VAMC.

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  • HadIt.com Elder
Posted (edited)

A long time ago, a good fried (Gene Groves) who has filed more CAVC appeals than any of us collectively ever will, argued there was a back door  on VACOLS. He had sent in 8 requests to stop further adjudication on an appeal temporarily.(Hamilton v Brown (1994)). Only five were visible. VA ignored him until it got dicey at the Court. He pointed out that some correspondence  that should be in VACOLS went missing. Then they magically reappeared. Turns out VA had been lying for years on this. McDonald had to admit they "found" a backdoor nobody seemed to know about. They plugged it-or said they did. VACOLS is no longer used except for the remaining Legacy Appeals. When they are gone, so too will VACOLS be shut down. 

With that said, let's look at CAPRI. CAPRI is not VistA. VistA is a compendium of all your VAMC medrecs. CAPRI docs are records copied from VistA and inserted into VBMS for adjudication purposes. Technically, neither can be altered. Don't confuse it with MyhealthyVet. MyhealthyVet is built for distribution to Vets but is not sacrosanct. I had a Vet who used Trulicity for DM II. VA refused to buy it for him. He raised a stink (before he died 7/1/2018). It was in his MHVet records they had refused him and tried to sub another drug... and then one day it (the refusal) wasn't there. When he died, his wife and I no longer had no access to it because of HIPPA. 

With access to VBMS, I see a lot of shenanigans like this. VBMS is not immutable. I've had ratings decisions appear which I objected to for error. I call or  email some poohbah and complain. Poof. Bye bye rating and a new one pops up in its place. I had one in Little Rock  that changed four times from 3/26/20 (denial); 4/1/20 (lowball 0% grant); 4/03/20 (redo w/ 30%) and one last one two  days before he died on 4/10 that upped him to 50%. Each earlier RD evaporated. I no longer trust them to be honest (if I ever did). I've had docketed appeals in AMA evaporate into thin air. When called out, they just recreate them and issue a RD as if nothing happened. Sadly, Vets have no access to VBMS or they'd be able to see this in real time. 

I have a dying Vet in Puerto Rico who asked 5 times over 50 yrs for his c file. Each time he got something new that wasn't in the file before. Finally, in 2014, all his STRs which burned up at the NPRC on 7/13/1973 surfaced and they granted SC. I confronted them on one x ray from 1971 that was "absent" and they just stuck it in and argued it was a duplicate.  When I see something important in VBMS, I screen grab it for later use. If I have to go to the Court, I will pitch a bitch about how a VA-authored document in their control can be magically ''disappeared''. So far, I've shamed them into submission or CUE'd them each time. 

All of you should be aware that VA seems to have changed over the years and become more adversarial instead of less. I'm not a conspiracy freak.  I feel it's individuals doing this- not the whole system. When you screw up, you tend to try to cover your tracks at any job... unless you're honest. Trust... but verify (or document it). 

And that's all I'm going to say about that. 

Edited by asknod
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Cushman vs Shinseki explains what happens when the VA commits fraud denying Vets benefits by altering the records:

Quote

Nothing.

Zip. Zilch. Nada.  VA must have used their "Get out of Jail Free" card.   There must be more of those cards at the VA someplace, because Im fairly certain, that Cushman was not the only one.    As far as I know, no VA employees were ever charged with a crime for altering a  Veterans records.  

I couldnt make something like this up:

Quote

In April of 1980, the Board affirmed the decision of the Regional Office.   Although the Board did not cite any particular evidence on which it relied in making its decision, the Board concluded that “the evidence fails to show the presence of symptomology which would preclude sedentary employment.”   The medical record before the Regional Office and Board, however, differed from the medical record on file at the DVA Outpatient Clinic.   Namely, one of the doctor's entries had been altered to change the language “Is worse + must stop present type of work” to instead read, “Is worse + must stop present type of work, or at least [ ] bend [ ] stoop lift.” (emphasis added, brackets indicate illegible or stray marks).   The altered record also contained the additional entry, “says he is applying for reevaluation of back condition,” which does not appear in the official record on file with the Outpatient Clinic.   The alterations appeared in the last, i.e., most recent, doctor's notes documenting Mr. Cushman's condition.

https://caselaw.findlaw.com/us-federal-circuit/1346393.html

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