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Treatment Notes

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grayling12

Question

On a previous post I discussed issues I'm having with my VA PCP. One problem with her is that she cuts and pastes my IBS treatment notes from one year to the next. This note just says that I have IBS and it bothers me, very descriptive, right?

Years ago I was awarded IBS at 0%, I was way worse than that, but my doctors only put the letters IBS in my treatment notes, so the VA had nothing to go by and awarded 0%. My VSO said it's an easy fix, just have your doctors put notes in my records indicating how bad my IBS is, then I can ask for an increase, simple right? It's been seven years now and I have exactly three notes in my records describing my IBS, and those are from the last six months. All of my doctors, VA and civilian don't feel like it's necessary to put descriptions in my notes. I think I finally convinced my civilian doctor to finally add the notes to my records.

I asked my VA PCP to write more descriptive notes about my IBS and she said repeatedly that it wasn't necessary. I tried begging with no luck, she stuck to her guns, she said it was completely acceptable to cut and paste. At this point I don't want to tell her that I'm trying to do an increase on my IBS, she probably already figured that out and that's why she won't help. 

On my next visit after my next wonderfull colonoscopy, I'm going to ask her one last time. I'm going to propose that since she is going to continue to cut and paste my notes, how about she write one paragraph describing how bad my IBS is, my symptoms, frequency, and severity, she can then cut and paste these updated notes from year to year, and I'll be just fine with that. I'm 100% positive she's going to refuse. If she does, I'm changing my provider. Unfortunately, when we were talking last time, I mentioned since she won't put any descriptions in my medical notes, that I was considering changing my provider, she literally laughed and said I wasn't going to have much luck with that. She said I wasn't going to be any happier with them than I am with her. That's not very promising, I live in a rural area without much selection.

Question:

1. Is there any other way to show how bad your IBS is, without a bunch of treatment notes to back you up?

2. Am I wrong in thinking that your doctors shouldn't have a problem describing your symptoms in your notes, my understanding from my VSO is that this is the only way to get an increase?

3. Would seeing a GI doctor do anything to help with the increase?

Thanks for any assistance!

 

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1.  Not really except for medical tests or a different doctor.

2.  You are correct.  My VAMC has a "box" where you can do things like asking for a change in provider (doctor).  If they dont, you can go to your "presidents office" (the head of your VAMC, not the American president), and explain your concerns, or the patient advocates office.  

3.  Probably..who knows "what a GI doc" will say.  However, if you have a serious problem, people often see a specialist.  I think you should do this, or consider changing provider.  Your choice.  

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If your doc is treating you that way, I'd file a complaint and ask for another doctor. Make sure you're documenting every interaction with her. 

This is why I hate VA and every other government-run health care. I'm not trying to be political, but the free-market doesn't put up with doctors and service like this for too long.

Semper Fi,

Sgt. Wilky

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Filing a complaint is all fine and dandy. Keeping a paper trail is very important. Just like the examiner has to comment on VA notes and its also available for you to read, can't you post your notes as well on myhealthevet about your concerns and or treatment? I have done it before and had gotten a phone call as well as a survey. I do not see that treating physician anymore in that clinic.

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Whodat, 

I have a different post recently about making the mistake of contacting my POS VA doctor on myhealthevet. She had a permanent note put in my medical records, saying that I'm an annoying patient, because I questioned her by messenger about how she was doing my treatment notes, and how I thought she was doing me wrong. The next time I complain ever in my life, it gets increased to a flag and then they start limiting my access to VA healthcare. Mind you, I was never given a warning that I was doing anything wrong. She got me targeted by saying that three messages in four days was excessive, and she said that I threatened her nurse because I put her nurses name in quotation marks. I was pointing out that her nurse was the one that tried refusing me medical care and I used quotation marks to emphasize her name as the one that was making my situation worse. The VA has essentially weaponized punctuation marks

I am going to request a new PCP and I mentioned this to my current PCP, and she actually laughed and said good luck, if you can't deal with me, you aren't going to have any luck with anyone else around here. I live in a rural area, not much of a selection close by. 

I know it's not going to do any good, but I am not going to stand by and get slammed by the VA for looking out for myself. I'm going to treat my letter writing campaign as a hobby. 

Is it common now for VA PCP's to not want to document in your treatment notes what is currently going on with your illnesses? 

Thanks everyone for the advice!

Edited by grayling12
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