Active duty medical records

[gangof4]

When I retired, I received my medical records which were unfortunately lost.  How can the VA research what I was treated for while on active duty if the original records were lost while in my possession?

[allansc2005]

@Dustoff 11,

 

I too have ran across some real screwballs at American Legion, DAV..et al, and have learned by trial and error to pick and choose who to seek help from, and who to wave off.

 

Having been on both sides of the fence of giving and taking advice concerning C&P matters, one thing has stuck in my mind-be HONEST!

 

The same American Legion I hung out at drinking beer, joking and smoking, is not the place where I would seek out advice on something as important as C&P!

 

Also, to give kudos where they are deserved, the guys and gals here also have helped a lot in my struggle for that high and mighty 100% status.

Great discussion.

 

So with no further ado, this old Major is off for an ice cold brewsky, at my local American Legion!

 

Allan 2-2-0 HOOAH!

 

 

 

 

[FloridaNative]

On 6/16/2022 at 11:13 AM, Lemuel said:

(for hard copy records--I do not know how to get data IPTR -- VA Hospitalizations are supposed to be obtained by the benefits division)

To get IPTR you need the dates of hospitalization.  Especially the date of admission.  Your military health record only contains a summary of that hospitalization.  On the top line of the summary is the date of admission and the date of discharge.  If your records got burned in the fire, it appears summaries were made of records sent to the bureau of personnel for your military unit. (Army, Navy or Airforce)

The summary should include the page 13 of the personnel records because a copy is sent to the bureau of personnel at each change of command or new set of orders.  

My knowledge is limited to NHMAT School 1968 in San Diego and my subsequent effort in 1992 or 3 to get Henry's IPTR for treatment of cerebral malaria and later my own for TBI.  If you do not request the specific IPTR with dates and facility you will only get the Military Health Record which only includes a summary of the hospitalization.  NPRC now has two or more buildings in which records are kept.  One is where the fire was and others are where, at some point the IPTR were collected from the various inpatient medical facilities.

 It appears the records are separated by facility and organized by admission date and then alphabetically the way they were packaged at the military hospitals when periodically boxed and shipped.  5 years old without a reoccurring visit for CONUS hospitals but I think the battle zone hospitals had to be more frequent.

It appears, from seeing others records, that if discharged recently all of your OPTR and IPTR are digitally accessible by the VA. 

Some community care records do not make it to the VA data base.  I think this is because sometimes the payment contractor does not upload the copy received to the VA file or it is misfiled by uploading to the wrong file.  At least some of my community care records are in my "Blue Button" download and others are not.

If you are having trouble getting your records, it is nice to be aware of 38 CFR 2.2 so that you can request a subpoena for them from a VARO with an office within 100 miles of the facility. 

CBOCs enter directly into the VA Data Base.

In my instance I contacted the facility I was last in and was told my records had been transferred to the National Archives. As in my previous post I began a months long quest to obtain copies of my medical records which I finally did. The VSOs I worked with were nice but not much help. They did do me a great favor though and had me file a notice of intent. As previously mentioned a few years of my VA health records disappeared. The VA blamed the loss on a facility move. I am a registered nurse. No longer practice but I still know how to read medical records and do medical research. In the course of reviewing the voluminous records (old Sears catalog size) I discovered a significant diagnostic error. I have chronic kidney disease rated at 80% along with other conditions that resulted in a rating of 100%. It appears someone took the easy way out and decided my type 2 diabetes was the cause. I discovered upon looking at my eye exam I had "no diabetic retinopathy" but I did have hypertensive retinopathy. Hypertension was one of the conditions I was service connected for. I confirmed my findings with my endocrinologist. My A1C blood sugar readings were over 7 only twice in 20 years. Occasionally they were in normal range. Under 7 isn't high enough to do the kind of damage my kidneys have. A later visit with a VA nephrologist further confirmed my findings. He told me after reviewing my records I have a profile of a prediabetic. With 1 exception (I had a qualified practitioner do my records review for 1 condition) I did my own scholarly research (via Google Scholar) and created files for each of the secondary and tertiary conditions. When I went for my comp physicals the examiners agreed with the research documents. I ended up with a 100% service connected rating on my first attempt. VSOs know which forms to file but do not have a medical background. I was told by one I saw that he would file my claim when I had a physician statement supporting my conclusions. I actually filed the claims myself online after I had all my research info. As I said before the VSO kept me from losing a year of benefits by having me file the notice of claim. For that I am forever grateful.

Edited June 23, 2022 by FloridaNative
additional information

[brokensoldier244th]

5 hours ago, FloridaNative said:

In my instance I contacted the facility I was last in and was told my records had been transferred to the National Archives. As in my previous post I began a months long quest to obtain copies of my medical records which I finally did. The VSOs I worked with were nice but not much help. They did do me a great favor though and had me file a notice of intent. As previously mentioned a few years of my VA health records disappeared. The VA blamed the loss on a facility move. I am a registered nurse. No longer practice but I still know how to read medical records and do medical research. In the course of reviewing the voluminous records (old Sears catalog size) I discovered a significant diagnostic error. I have chronic kidney disease rated at 80% along with other conditions that resulted in a rating of 100%. It appears someone took the easy way out and decided my type 2 diabetes was the cause. I discovered upon looking at my eye exam I had "no diabetic retinopathy" but I did have hypertensive retinopathy. Hypertension was one of the conditions I was service connected for. I confirmed my findings with my endocrinologist. My A1C blood sugar readings were over 7 only twice in 20 years. Occasionally they were in normal range. Under 7 isn't high enough to do the kind of damage my kidneys have. A later visit with a VA nephrologist further confirmed my findings. He told me after reviewing my records I have a profile of a prediabetic. With 1 exception (I had a qualified practitioner do my records review for 1 condition) I did my own scholarly research (via Google Scholar) and created files for each of the secondary and tertiary conditions. When I went for my comp physicals the examiners agreed with the research documents. I ended up with a 100% service connected rating on my first attempt. VSOs know which forms to file but do not have a medical background. I was told by one I saw that he would file my claim when I had a physician statement supporting my conclusions. I actually filed the claims myself online after I had all my research info. As I said before the VSO kept me from losing a year of benefits by having me file the notice of claim. For that I am forever grateful.

VSOs also have VBMS access (many of them, anyway) and so can access documents directly in your file. The issue is time. There is 1 of them, and 200+ veterans or more at a given time that they keep track of. I filed 1 claim with a VSO in 2002. All of them after were filed by me. Over the next 13 yrs I got to 100% P&T, though, I wouldn't say I was a 'winner'. I still loop in my DAV VSO office in anything I do if for no other reason than I need access to something in VBMS, or some kind of confirmation of something being there. Sometimes they reply, sometimes they don't, so I follow up. I don't begrudge them much, though, if they don't always get back to me, and here is why.

I work for VA as a VSR, and I see the amount of stuff in VBMS files for veterans. The filing system is a mess- its by date order, so if you upload a chunk of 100 pages of something it shows up at the top as 1 link that opens with 100 pages attached. Even if that 100 somethings consists of documents from 20 yrs ago its a 'new' upload, so this is why you all have 20 duplicates of things strewn throughout your files. Your uploads are named under a heading with about a 100 character limit of "whatever you called them when you uploaded them...." or, if you mail them in unlabeled, whatever the Janestown intake calls them- usually "Correspondence"- they don't read your stuff, either- its outside their wheelhouse. This is the most generic, useless heading ever because it says NOTHING about whats in it, how many pages, whatever.

Incoming VA forms are usually caught by the system if you upload them individually by the OCR (optical character recognition) and labeled correctly, but that partial STR from 1987 that you uploaded with no descriptive name? 1 link, in a page of links 50 deep, named "correspondence". A veteran VBMS file may have 20,30,50, whatever, PAGES of links like this. OCR also only reads typing about 75% of the time (anecdotal guess) and barely reads handwriting, so that medical scrawl from that corpsman 15 yrs ago still has to be deciphered by me. At least in the last 15 yrs or so most medical and personnel files are digital now, so when they are uploaded they are easier for Adobe to 'read', so long as the numbnuts at Soldier OneStop didn't upload the pages as images of PDFs instead of PDFs. In that case I have to break them all out and convert them back to straight PDFs, and that can take Adobe up to an hour or more depending on the size of the file. And that's if it doesn't choke on it along the way and time out. 

I spend as much time in random veteran files that I am working on labeling stuff that isn't even relevant to the claim I'm working on at least with a descriptive heading or date range so the next person that looks in your file at least has some idea of what they might be opening. Multiply this by 900,000 or whatever the number of claims is lately, and you can hopefully empathize at least a little but with what we (VSR) and VSO's see when we look in your file. As much as I or they would like to read the novel of your military and post military life we have 10-15 other veterans a day on average to look through. 

 

If you want to make your life easier: 

1. label your uploads something meaningful and maybe with a date-range, also

2. Pre-prep your uploads a little bit- whip out that highlighter or pen and underline, highlight, write notes in the margins, whatever, the main highlights

3. Consider a coversheet or covernote- Name, SS#, brief description of what you are claiming/supporting with this upload, and a few sentences about what it is an how it relates to what you are claiming. It doesn't need to be Shakespeare, or medical-ese. Please don't- if you aren't a doctor, or quoting one, don't just start typing stuff from WebMd or whatever to try to self diagnose. If you aren't a doctor or medical person, its not a diagnosis, and therefore is just the equivalent of a lay-statement. Uploading medical studies? If you weren't in the study specifically, its not weighty as probative evidence. Sure, it may support your contention, and if it does GREAT! I love that, awesome, I get to feel like its a tiny win for you. But you still need someone medical to say that whatever that study concluded applies to you for it to have much weight. 

4. Phone reps are NOT cleared the same as VSRs or Raters- thus they cannot see VBMS. They can see the notes that we leave on actions taken, usually, and they can maybe see a listing of what documents are in there, but see what I typed above about how they are named, and then remember that they aren't trained nearly as much on 'what' those documents are or 'what' they mean. They type up a report of contact (0820) and upload it with whatever your question/concern/rant was and I see it later. Sometimes I can answer whatever it was with a letter, or I can take the information as it was relayed and use it to find things in your file, clarify something, correct something like an address, name, gender, appt date or scheduling, etc. Sometimes I can't, because their description isn't always the greatest. Still- your calls ARE documented and those reports are uploaded into VBMS.

Sidenote-- KEEP YOUR ADDRESS and PHONE NUMBER UPDATED!! If something gets bounced back to us because of non-delivery we can't just go DeepSearch the postal service or whatever and find you. Thats how you sometimes end up with no notification of something, like "hey, we need *this form* or *you missed an exam, why, I can't reschedule it until I know why, and even then if its just a straight no-show with no reason, I usually can't because "no-show" with no good reason is considered waiving your rights to an exam, and it will go to rating with whatever is of record, and thats it.

I have some tricks and processes I can use to try to find you, like looking into your VHA file to see what address or phone you have on file there, but if its not correct either, well, there are things that can be held up on your claim because we can't contact you. 

 

Thus endeth the lesson, time to get ready for work, y'all.

 

 

Edited June 23, 2022 by brokensoldier244th

[Lemuel]

3 hours ago, brokensoldier244th said:

VSOs also have VBMS access (many of them, anyway) and so can access documents directly in your file. The issue is time. There is 1 of them, and 200+ veterans or more at a given time that they keep track of. I filed 1 claim with a VSO in 2002. All of them after were filed by me. Over the next 13 yrs I got to 100% P&T, though, I wouldn't say I was a 'winner'. I still loop in my DAV VSO office in anything I do if for no other reason than I need access to something in VBMS, or some kind of confirmation of something being there. Sometimes they reply, sometimes they don't, so I follow up. I don't begrudge them much, though, if they don't always get back to me, and here is why.

I work for VA as a VSR, and I see the amount of stuff in VBMS files for veterans. The filing system is a mess- its by date order, so if you upload a chunk of 100 pages of something it shows up at the top as 1 link that opens with 100 pages attached. Even if that 100 somethings consists of documents from 20 yrs ago its a 'new' upload, so this is why you all have 20 duplicates of things strewn throughout your files. Your uploads are named under a heading with about a 100 character limit of "whatever you called them when you uploaded them...." or, if you mail them in unlabeled, whatever the Janestown intake calls them- usually "Correspondence"- they don't read your stuff, either- its outside their wheelhouse. This is the most generic, useless heading ever because it says NOTHING about whats in it, how many pages, whatever.

Incoming VA forms are usually caught by the system if you upload them individually by the OCR (optical character recognition) and labeled correctly, but that partial STR from 1987 that you uploaded with no descriptive name? 1 link, in a page of links 50 deep, named "correspondence". A veteran VBMS file may have 20,30,50, whatever, PAGES of links like this. OCR also only reads typing about 75% of the time (anecdotal guess) and barely reads handwriting, so that medical scrawl from that corpsman 15 yrs ago still has to be deciphered by me. At least in the last 15 yrs or so most medical and personnel files are digital now, so when they are uploaded they are easier for Adobe to 'read', so long as the numbnuts at Soldier OneStop didn't upload the pages as images of PDFs instead of PDFs. In that case I have to break them all out and convert them back to straight PDFs, and that can take Adobe up to an hour or more depending on the size of the file. And that's if it doesn't choke on it along the way and time out. 

I spend as much time in random veteran files that I am working on labeling stuff that isn't even relevant to the claim I'm working on at least with a descriptive heading or date range so the next person that looks in your file at least has some idea of what they might be opening. Multiply this by 900,000 or whatever the number of claims is lately, and you can hopefully empathize at least a little but with what we (VSR) and VSO's see when we look in your file. As much as I or they would like to read the novel of your military and post military life we have 10-15 other veterans a day on average to look through. 

 

If you want to make your life easier: 

1. label your uploads something meaningful and maybe with a date-range, also

2. Pre-prep your uploads a little bit- whip out that highlighter or pen and underline, highlight, write notes in the margins, whatever, the main highlights

3. Consider a coversheet or covernote- Name, SS#, brief description of what you are claiming/supporting with this upload, and a few sentences about what it is an how it relates to what you are claiming. It doesn't need to be Shakespeare, or medical-ese. Please don't- if you aren't a doctor, or quoting one, don't just start typing stuff from WebMd or whatever to try to self diagnose. If you aren't a doctor or medical person, its not a diagnosis, and therefore is just the equivalent of a lay-statement. Uploading medical studies? If you weren't in the study specifically, its not weighty as probative evidence. Sure, it may support your contention, and if it does GREAT! I love that, awesome, I get to feel like its a tiny win for you. But you still need someone medical to say that whatever that study concluded applies to you for it to have much weight. 

4. Phone reps are NOT cleared the same as VSRs or Raters- thus they cannot see VBMS. They can see the notes that we leave on actions taken, usually, and they can maybe see a listing of what documents are in there, but see what I typed above about how they are named, and then remember that they aren't trained nearly as much on 'what' those documents are or 'what' they mean. They type up a report of contact (0820) and upload it with whatever your question/concern/rant was and I see it later. Sometimes I can answer whatever it was with a letter, or I can take the information as it was relayed and use it to find things in your file, clarify something, correct something like an address, name, gender, appt date or scheduling, etc. Sometimes I can't, because their description isn't always the greatest. Still- your calls ARE documented and those reports are uploaded into VBMS.

Sidenote-- KEEP YOUR ADDRESS and PHONE NUMBER UPDATED!! If something gets bounced back to us because of non-delivery we can't just go DeepSearch the postal service or whatever and find you. Thats how you sometimes end up with no notification of something, like "hey, we need *this form* or *you missed an exam, why, I can't reschedule it until I know why, and even then if its just a straight no-show with no reason, I usually can't because "no-show" with no good reason is considered waiving your rights to an exam, and it will go to rating with whatever is of record, and thats it.

I have some tricks and processes I can use to try to find you, like looking into your VHA file to see what address or phone you have on file there, but if its not correct either, well, there are things that can be held up on your claim because we can't contact you. 

 

Thus endeth the lesson, time to get ready for work, y'all.

 

 

So, how is it that I updated my new address within a month of leaving to it and things got sent to addresses that were more than a year old and therefore not transferred.

The only reason I can see is that the RO or DRO assumed permanence of address from the document they last looked at.  Sometimes things were sent to two or three prior addresses and the new address was on the document they were responding to.

[Lemuel]

9 hours ago, FloridaNative said:

In my instance I contacted the facility I was last in and was told my records had been transferred to the National Archives. As in my previous post I began a months long quest to obtain copies of my medical records which I finally did. The VSOs I worked with were nice but not much help. They did do me a great favor though and had me file a notice of intent. As previously mentioned a few years of my VA health records disappeared. The VA blamed the loss on a facility move. I am a registered nurse. No longer practice but I still know how to read medical records and do medical research. In the course of reviewing the voluminous records (old Sears catalog size) I discovered a significant diagnostic error. I have chronic kidney disease rated at 80% along with other conditions that resulted in a rating of 100%. It appears someone took the easy way out and decided my type 2 diabetes was the cause. I discovered upon looking at my eye exam I had "no diabetic retinopathy" but I did have hypertensive retinopathy. Hypertension was one of the conditions I was service connected for. I confirmed my findings with my endocrinologist. My A1C blood sugar readings were over 7 only twice in 20 years. Occasionally they were in normal range. Under 7 isn't high enough to do the kind of damage my kidneys have. A later visit with a VA nephrologist further confirmed my findings. He told me after reviewing my records I have a profile of a prediabetic. With 1 exception (I had a qualified practitioner do my records review for 1 condition) I did my own scholarly research (via Google Scholar) and created files for each of the secondary and tertiary conditions. When I went for my comp physicals the examiners agreed with the research documents. I ended up with a 100% service connected rating on my first attempt. VSOs know which forms to file but do not have a medical background. I was told by one I saw that he would file my claim when I had a physician statement supporting my conclusions. I actually filed the claims myself online after I had all my research info. As I said before the VSO kept me from losing a year of benefits by having me file the notice of claim. For that I am forever grateful.

Thanks for the information.  I am trying to follow your lead.

[Phury & Rhage]

On 6/15/2022 at 8:15 PM, Richard1954 said:

When I retired in 1986 I was handed my active duty medical records as I was handed my walking papers at Fort Dix.

Back in my day they were still using microfich and data punch cards , we didn't have digitial records. 

I still have my original records...

I got out on March 2, 1986 in Ft. Richardson, AK, and I was handed my original medical records.  I was a Personnel Management Specialist at the time and worked at Post level.  It is entirely possible that it was Department of the Army policy (bad, bad policy, lol) at the time to give out the originals.  I don't remember being told to do anything with them either.  I'm  pretty sure I still have them in a storage container somewhere.  The bulk of my service after the Army (with a 5+ year break in service) was with the Air Guard and most of those records were available for VA claims.

If you were hospitalized, there is a good chance that those records were sent to NPRC after 10 years.  VA has to put in separate requests for events that occurred over multiple years, so try to identify when any treatment occurred.  M21-1, III.ii.2.C.1.a.  When Clinical Records Are Retired.  If you were issued a physical profile (temp/perm duty restrictions for a particular condition) for any medical condition, a copy of that might be in your personnel file.  I wasn't given my original personnel file and I really hope you weren't either.  You can obtain a copy of those records from NPRC as well.

Good luck to you,

Phury