I just wanted to post my recent experience with my medical records, so everyone in the military might benefit from my experience and possibly prevent some serious disability rating/diagnosis/fraud issues.

Here's my story:

I am a disabled vet receiving %100 IU because I am unable to work, and have severe degenerative problems associated with my back and nerves.

I recently applied for SSDI, after finally admitting to myself and my wife that I cannot work to support our family. As part of that process, the Soc. Sec. Admin. asked that I send them my medical records. I did so, but because my medical problems are ongoing, I also needed to provide my records from April and May(during this time the SSA had already received my records prior to April, and was reviewing my claim).

Well, I didn't bother to look at my medical records that I sent the SSA prior to April; they must be correct, you can't get an MRI or X-Rays, or a doctor's dictation WRONG, right?

But for the Heck of it, I picked up my latest records for April/May in person, and looked through them. Let me tell you I was absolutely shocked. (If this board allowed, I would be adding colorful expletives right now.)

There were outright lies, misrepresentations, and glaring omissions! One example of total horse-pucky is as follows...

I arrive in the emergency room, barely able to walk, doubled-over in pain, near passing out. The doctor asks me, "How are you doing? You don't look so good!" I replied, using the good manners my parents instilled in me, "Fine doc...except that I've been in so much pain I haven't slept the last four days, even taking 8 Tramadol pills a day plus the Cyclobenzaprine I was given!" Now here is what you will not believe-- My official record of this visit states only that "The patient says he felt fine." And below that line, the date I arrived at the ER!! No mention of my severe pain, no mention of my lack of sleep, no opinion given of the doctor regarding his opinion of what was going on. I was also told in person by various docs/neurosurgeons that I have spinal stenosis, complete arthritis of the spine, degenerative disc disease, permanent nerve damage, etc. But do you know what it says in my permanent record? "Bulging disc L5-S1 causing distress. Diskectomy performed." and most recently, "L4-5 and L3-4 disks presenting mild protrusion."

These docs told me to my face how severely messed-up I am, yet none of them wrote ANYWHERE in my records the severe nature of my problems.

Most recently, I had an appointment with my neurosurgeon who performed my first surgery. He told me that I had scar tissue impinging on my nerve/s and that it was responsible for my disabling sciatic pain. He said it would be pointless to remove this tissue, as it would only reform again. I told him how I now could not walk without tripping, because my left leg goes limp without warning; how from my waist down I go completely numb after sitting in a chair for a few minutes; how I can no longer make love to my wife because of "problems" in that area. He told me that the nerve damage was permanent, the pain caused by the scar tissue would be lifelong, he brushed-off the sexual aspect completely, and said I could try an epidural injection if I wanted.

But what did my official record say of this visit? "Patient has mild protrusion of L-3, L-4 discs. Will recommend epidural injection."

Oh yes, I forgot to mention, that I brought him a college loan forbearance form to sign, stating that I was disabled and unable to work to repay my loan. (I still want to repay it somehow, perhaps with income from my wife if she works once our children are a little older.) The doctor read the whole form, and signed it.

What does this tell me? He was unwilling to state the severity of my condition in my official medical records, yet basically told me I WAS disabled. (I know that anyway...)

I could continue on, presenting numerous other such discrepancies with my medical history, but I think you all get the point. At this point, considering that no doc wanted to put down in writing how badly-off I am, I am MYSTIFIED as to how my IU claim was ever approved at all!

I just thank God for the blessings I have already received, and hope that everyone out there takes the time to review their own medical records to see just how "accurate" they truly are!

I am not so much worried about winning my SSD claim-- of course my family needs the money, but there is a much larger issue here. Can I trust the medical advice/ diagnoses I have been given thus far, given the dishonest nature of my records?

I am now seeking a second opinion, and luckily for me, I asked the MRI tech who did my exam to burn me a cd copy of my results. I also have two cousins who are doctors; I have discussed my problems with one, she has already told me that I should have surgery immediately. I am already guessing my other (competent, unlike my VA docs,) doctor-cousin will agree that surgery is needed.

Thanks all for reading, and I hope you will take the time to review your own records. May God bless all of you that have served our country, and your families as well!!

I wanted to add that I should have read the "rules for posting" thread first; I did not do so, and apologize that the content of my thread is not specifically about "missing records."

However, in my humble opinion, the fact that there were serious omissions/misrepresentations in my medical records is deserving of discussion. This is a serious issue for all vets. As an example, let us say that a vet wanted to apply for an increase in disability rating; his doctor gave him an honest medical opinion of his condition, then discussed with him the serious nature of his health. This vet assumes that he has grounds to file a claim. What happens then, when a Medical Exam Board reviews his records and finds that the doctor he spoke to did not record ANY of these serious findings?

To the moderators, if this post would not be allowed in this forum, PLEASE, PLEASE do not delete it, rather move it to another forum where it can be read. The future health and well-being of our service men and women MUST be recorded in their medical records with INTEGRITY and ACCURACY.

Thank you again sincerely for reading.

I had a talk with one of the VA docs in the department I see. That changed how I start out every visit. He had taken care of me in private practice in the hospital when his partner was out of town and had known him for 5 years. He had seen me a few weeks before when my appointment got mismatched with my doctor.

I have been trying for 5 years to get my status upgraded to permanent from temporary. We discovered I was going about it wrong. Now every visit I start with what has gone wrong since the last visit. I no longer say I am doing fine. I told the doctor when we started why, and he agreed. You must start with the hell of you disease, and then say how you cope.

We all tend to try and be brave and minimize things. The problem is that for the records we need it to start bad.

Also, note that there is a conflict of interest in a family member certifying a disability for a family member. Also the AMA frowns on doctors treating family members.

Thanks for the info, and sorry for the lateness of my reply; my internet was out for 4 days.

My cousins also agree that they do not want there to appear to be bias in regard to having a family member deal with these sorts of issues. Therefore, they have referred me to another neuro-radiologist who can give me an unbiased 2nd opinion of my condition.

The point about attempting to minimize my condition is well taken; I also appreciate the wisdom of beginning each visit with discussing the debilitating nature of my condition and not engaging in polite and smalltalk, as that may cause the physician to assume that I am really not too bothered by my condition (which is in diametric opposition to the truth!)

Thanks again, and I hope my above post has served some use for others.

know for a fact they put things in you record that are false or that are their oppinon and not what is really happening. There are ways of having this changed but the process is hard. you have to write them and explain that these things need to be removed due to fraud. They will omit them or fix them.

I have been fighting with both the ssdi about my medical records and the fact they didnt even use my VA records.

The fact is you let them know straight up you are getting your records that you go over them and you know what is being put in them. And it is a good thing to get records every 6 months or so. they do put the wrong info in and sometimes put info that is for another paiten all together. They tend to be on gaurd if they know you are checking up on them ....
complaints go to the reginal offices....

thats why one should make copies of everything in their medical records!
I asked for my medical record just a week or so after I got discharged and they told me that they "could not find it"
just 1 week and they could not find it. Luckily, I made tons of copies for myself prior to getting out and have copies of everything but my final physical.

Do they not realize how bad this makes them look?

the milatary doctor was caught destroying my med records he didnt know I had copied the most of them. If I hadnt copied them I would have not got my disablity. I urge every one to copy them and keep copies .

I went to the C&P physical exam in 04 when I retired. I had a bit of an idea what to expect from the VA since I was a Medic for 20 years. I was surprised to say the least. It was almost like my very first Army physical, only not as proficient or thorough! I wont go into detail on the conditions that I listed on my VSO forms, but one that WAS NOT listed!

I was shocked when the doctor asked me to lower my pants to perform a“ turn your head and cough” hernia exam. Being trained by 4-5 PAs (Physicians Assistant) and knowing how to check for a hernia, having done at least 150 of them. Still, I did what he asked and “dropped trou”. To my amazement he started to tickle my scrotal area with his fingers. After a few seconds of this he stopped and stood up and said “well, I don’t think you have a hernia”. I pulled up my shorts and then looking him in the face I told him, “doctor, I was a medic in the Army for 20 years and that was not how to check for a hernia”! His face got red… looking like he got caught in the cookie jar. Soon after that he said he was done, and that I could go back to the front office for the rest of the C&P.

I did put in a patient complaint against this doctor. I went down to the patient representative’s office and told her exactly what had happened! She told me she used to work up in the C&P and that did not sound like something this doctor would do! I gave her my full contact information and everything else. I wrote out the complaint. I also asked to be contacted by the hospital administration about this doctor. 3 years later… nothing yet!

Last week I asked to get copies of all my recent visits to the VA hospital. In the paperwork I read that I had 80% rated, but that I was paid for 60%. I also found a new “Aliment” that I did not know I had! A HERNIA…!!! Rated at 0% of course.
Talk about falsifying a medical record…

At this time, I’m looking for a Doctor that will go though my medical record and see what is right or missing and what treatment I should have been getting for my injuries and aliments. A Doctor that works pro-bono or at least one I can afford! I don’t want to go to my Congressman or Senator until I get an un-biased medical opinion about my medical treatment.

ReaperDoc

I am a vet and am really confused. I read a letter from one fellow praising the VA. Jackfran@peoplepc.com

quote:

Originally posted by ReaperDoc:
I went to the C&P physical exam in 04 when I retired. I had a bit of an idea what to expect from the VA since I was a Medic for 20 years. I was surprised to say the least. It was almost like my very first Army physical, only not as proficient or thorough! I wont go into detail on the conditions that I listed on my VSO forms, but one that WAS NOT listed!

I was shocked when the doctor asked me to lower my pants to perform a“ turn your head and cough” hernia exam. Being trained by 4-5 PAs (Physicians Assistant) and knowing how to check for a hernia, having done at least 150 of them. Still, I did what he asked and “dropped trou”. To my amazement he started to tickle my scrotal area with his fingers. After a few seconds of this he stopped and stood up and said “well, I don’t think you have a hernia”. I pulled up my shorts and then looking him in the face I told him, “doctor, I was a medic in the Army for 20 years and that was not how to check for a hernia”! His face got red… looking like he got caught in the cookie jar. Soon after that he said he was done, and that I could go back to the front office for the rest of the C&P.

I did put in a patient complaint against this doctor. I went down to the patient representative’s office and told her exactly what had happened! She told me she used to work up in the C&P and that did not sound like something this doctor would do! I gave her my full contact information and everything else. I wrote out the complaint. I also asked to be contacted by the hospital administration about this doctor. 3 years later… nothing yet!

Last week I asked to get copies of all my recent visits to the VA hospital. In the paperwork I read that I had 80% rated, but that I was paid for 60%. I also found a new “Aliment” that I did not know I had! A HERNIA…!!! Rated at 0% of course.
Talk about falsifying a medical record…

At this time, I’m looking for a Doctor that will go though my medical record and see what is right or missing and what treatment I should have been getting for my injuries and aliments. A Doctor that works pro-bono or at least one I can afford! I don’t want to go to my Congressman or Senator until I get an un-biased medical opinion about my medical treatment.

ReaperDoc