Med records wrong...should I request correction?

Hello,

Well here begins my slew of questions for the experts here. I will be undergoing an MEB....I am not entirely sure at what date (still require a few surgeries).

I want to make sure that all my ducks are in a row and that I am the most educated on the entire scope of the MEB/PEB process.

Here is my question/situation:

I know that my medical records have had errors in the past. I have found other people's documentation in the records on two separate occassions while transporting my records to another doctor outside of the MTF. I also have been attempting to get some issues resolved, but the doctor dismisses (or had dismissed) some of the concerns I have had. Specifically, follow ups/treatment was not accomplished and when I requested that someone tell me where to go/what to do I was kind of ignored.

I also know that one of my issues is a direct result of an incident that happened a year and a half ago, however, it was not documented properly in my med records.

Should I formally request in writing (from AFI 41-210) a correction to my records? What if there are NUMEROUS errors?

My reason for asking is I feel that many of the injuries I have may lead to being retired from the USAF medically...I dont want to do this but I want to ensure that if indeed this happens, nothing comes up missing or was never documented when dealing with VA ratings and disability.

I have a strange feeling that this may be a very rocky road and I want to tread carefully......

Thanks in advance....I appreciate your candor....

Mike
 
Hello,

Here is my question/situation:

I know that my medical records have had errors in the past. I have found other people's documentation in the records on two separate occassions while transporting my records to another doctor outside of the MTF. I also have been attempting to get some issues resolved, but the doctor dismisses (or had dismissed) some of the concerns I have had. Specifically, follow ups/treatment was not accomplished and when I requested that someone tell me where to go/what to do I was kind of ignored.
Hello MikeMN!

Sounds like you have a few different issues. As a start point, you need to decide what is right for your own case. But I will give you some thoughts. First, you can request correction of your records under the Privacy Act. What is an interesting question is if someone else's records even counts as your own record. I would think that most reviewing officials (i.e., MEB or PEB) would catch the error, unless your names were very similar. I see no risk in asking them to remove these records (the other question is if this was just someone else's file getting moved into yours by accident, i.e., if the file was next to yours and the papers accidently got combined with yours. Just for interest, I would want to know if these records are in your electronic records).
The other issue you raise is getting follow up care. Many routes you could pursue here, from taking another run at your PCM, going through patient advocacy/ombudsman at your MTF, or seeing if you can get an independent medical opinon (on the governments dime or yours, if they won't...you can check with TriCare on the referral process). Take the first step and try to talk to your PCM, stating clearly and persistently your concerns.

I also know that one of my issues is a direct result of an incident that happened a year and a half ago, however, it was not documented properly in my med records.
Sounds like you need an LOD. For active members, LODs may not be done as often, as the issue of entitlement to benefits is often clearer. But you can ask your chain of command about an LOD. If you are trying to document for purposes of combat related, there are a number of avenues to consider (including awards citations, After Action Reviews, unit history, unit diary, statements from supervisors, etc.). If you give more details, this may make narrowing your options easier.

Should I formally request in writing (from AFI 41-210) a correction to my records? What if there are NUMEROUS errors?
Again, you have to judge for yourself whether you should do this. My general view is that if the errors don't impact your case, I would not worry about it too much. It is best to have an accurate record, but, for example, if they say that you came to the clinic and were wearing a blue shirt instead of a red shirt, it won't impact your case. If you are talking about issues that may substantively impact your case, then you may want to request the correction (I would cite the Privacy Act, too). Another thing to consider is that if the issue does not impact your case, but are pervasive, sometimes it can be used to argue they did a bad job in documenting your case.

My reason for asking is I feel that many of the injuries I have may lead to being retired from the USAF medically...I dont want to do this but I want to ensure that if indeed this happens, nothing comes up missing or was never documented when dealing with VA ratings and disability.

Makes sense.

I have a strange feeling that this may be a very rocky road and I want to tread carefully......

Thanks in advance....I appreciate your candor....

Mike
Best of luck, I hope it all goes well for you.
 
MikeNM,

I wouldn't be too concerned as long as the information submitted to the board is accurate and current for your medical conditions in question for continued service.

According to the AFI41-210 "Any reports, consults, that are over 90 days old and MEB narrative summaries over 30 days old will not be adjudicated and will be returned to the MTF commander for correction".

AFI41-210 page 138:
10.7.2. Responsibility. It is the responsibility of the board president and the reviewing officer to
ensure that the best available medical information is in the narrative summary. If the narrative summary
is deficient in the laboratory or radiology results, or required reports or consults listed in paragraph

[FONT=TimesNewRoman,Bold][FONT=TimesNewRoman,Bold]10.7.1.[/FONT][/FONT][FONT=TimesNewRoman,Bold]
[/FONT], the board president or reviewing authority should return the narrative summary to the

preparing physician for clarification or updating. The board report must stand alone during the adjudication
process at the Informal PEB, Formal PEB, the Secretary of the Air Force Personnel Council
(SAFPC), Assistant Secretary of Defense (Health Affairs), and the Physical Disability Appeals Board
(PDAB). Any reports, consults, that are over 90 days old and MEB narrative summaries over 30 days


old will not be adjudicated and will be returned to the MTF commander for correction.

Records Correction:

You could subimit a request to have your records corrected, but, be aware that the request can be denied per AFI41-210. But, given your reasons, I don't see any reason why your request would be denied. If your request is accepted, then the MTF has to correct the numerous errors you mentioned. Plus, you stated other peoples info. was in your records.

If you do submit the request, ensure the timing is good for you, and hopefully, your request will not disturb the MEB process (probably best to ask for corrections well before the start of the MEB if you want it done before the board meets for peace of mind).

This is from the AFI:

[FONT=TimesNewRoman,Bold]4.3. Correcting Health Records.[/FONT]
4.3.1. Patients have the right to see their health records and request amendment if they think the documentation
is in error. There is no requirement to agree to the amendment and at no time should any
documentation be removed from the record unless it is determined that the documentation is not on
the patient whose record is in question. The MTF record amendment policy will detail the requirements
for patient’s requests. Follow these processes upon receipt of a patient’s request for amendment.
4.3.2. The request to amend the record must be made in writing, see [FONT=TimesNewRoman,Bold][FONT=TimesNewRoman,Bold]Figure 4.1.
[/FONT], and be signed by the
patient or guardian and filed in section 3 of AF Form 2100A or left side of AF Form 2100.
4.3.3. Reply to the requestor, in writing, within 60 days with either an acceptance or denial of the
amendment. If this is not possible, a 30-day extension is allowed. However, the MTF will inform the
patient, in writing, about the extension. The letter will include a reason for the delay and a date the
response will be provided. Only one extension is allowed per amendment request.
4.3.4. Denial of requests is allowed if any of the following conditions are met:
4.3.4.1. The protected health information is not part of a designated record set available for
inspection under HIPAA.
4.3.4.2. The information requested to be amended is actually accurate and complete.
4.3.4.3. The MTF did not originally create the protected health information requested for amendment
(e.g., copies of records from treatment at another MTF or civilian facility provider). However,
if the requestor can prove that the MTF which originally created the information no longer
exists, the MTF will handle the request as if it had created the information.
4.3.5. Upon receipt of a request for record amendment, forward it immediately to the applicable provider
for research.
4.3.6. Take the following action when a minor error is identified near in time to the erroneous entry
date and the responsible practitioner has current memory of the circumstances.
4.3.6.1. Line through the incorrect data with one straight line. Do not erase, scratch out or otherwise
destroy the original data. Amendment of erroneous data should be done by the originating
practitioner. If that is impractical, enter a brief explanation of why the originating provider did not
make the correction. Enter the correct data next to the lined through data if space permits. Only
providers privileged to document patient care will make corrections. The date for all entries or
corrections must be the actual date of the notation.
[FONT=TimesNewRoman,Bold]50 AFI41-210 22 MARCH 2006[/FONT]
4.3.6.2. If there is not enough space on the record next to the incorrect data to enter the correction,
draw one straight line through the entry, initial, date and make a referral note to where in the
record the correction is documented. Then enter the correction chronologically as indicated on the
referral note. If the correction is not self-explanatory, also enter the reason for the correction. Provider
will sign, date, and stamp the new entry. If other practitioners are associated with the
patient’s care and have a need-to-know concerning the change, inform them of the correction.
Major changes may require documentation on a separate form (i.e., a new, blank form). Follow the
same procedures stated above and file the corrected information as near as possible to the document
containing the lined through information.
4.3.7. Take the following action if an error is identified after a claim or lawsuit has been filed or after
a substantial time lapse:
4.3.7.1. Do not automatically amend the record as outlined in paragraph [FONT=TimesNewRoman,Bold][FONT=TimesNewRoman,Bold]4.3.6. [/FONT][/FONT]when the adequacy
of care has been challenged by the patient. Any amendment of the actual record is likely to create
an appearance and allegation of record tampering. Consult the SJA or area medical law consultant
for guidance.
4.3.7.2. The practitioner with personal knowledge of the erroneous data, prepares a separate statement
of fact with the assistance of the SJA. The statement becomes a part of the claim or litigation
file. Notify all practitioners involved with the patient’s care if the erroneous data could affect the
patient’s future care.
4.3.8. Active duty members who believe their medical records contain erroneous information may
apply to the Air Force Board of Correction of Military Records, SAF/MIBR, 550 C Street West, Suite
40, Randolph AFB TX 78150-4742. The MTF will take no action until contacted by the board representatives.
See the “Guide to Processing Applications to the Air Force Board for Correction of Military[/FONT]​

Records (AFBCMR)”, dated 20 June 1995.

I posted the info. from the AFI for others to view who may be interested in how the process works for the AF.

I hope my input helps.



 
Jason and Purple,

Thanks for the insight!

Jason...what is LOD? Are we speaking of Line of Duty? The injuries I have now were a result of an aircraft incident little less than 2 years ago. I thought nothing of it at the time but we declared and emergency and I was taken to the VA med center ER for treatment. Couple of scratches on my arm, loose molar, and it felt like my shoulders popped out. I was assured that the shoulders were fine.....turns out they weren't. One way or another, I will have to leave service....dont want it sooner as I love my job. However, when it comes time for retirement, I want to ensure that my records are accurate when it comes to % rating time.

I agree on the colord shirt example below...makes alot of sense.

Purple...when you highlighted "Any reports, consults, that are over 90 days old and MEB narrative summaries over 30 days old will not be adjudicated and will be returned to the MTF commander for correction." ....what did you interpret this to mean?

It may be staring me in the face but I am still a bit confused on that statement.....

Best wishes! I will be seeing my PCM this morning and will ask a few ???'s.

Thanks for the help and support!

Mike:)
 
Trying to remember, it was after 2am when I wrote it, and I haven't been to sleep yet...

Oh,

When it was time for my MEB, I had to stay on top of my consults to make sure the information was current (as far away from 90 days as possible). And my PCM did a good job ensuring the narritive summary did not go near the 30 day window before the MEB convened.

I just wanted you to be aware of the timeframes if you didn't know already. Just trying to help...I probably shouldn't have highlighted the information. I apologize, I did not mean to confuse you.

I think I should probably go to bed now.

Good luck with your appointment.
 
Purple...

No apologies necessary whatsoever! Very good and helpful information.

Appointment went well. Doc will not even start the MEB process until the surgeries I need will be done and we know the results. He also clarified some of the information that was not in the records for me.....I feel much better after the discussion!

Where do I go from here? Well I will be getting a copy of the records here in the next few weeks to be sure....any issues doc and I will discuss. I really feel as though he is truly on my side and very willing to help.

Ill keep you posted on the situation as it unfolds! Hopefully my 'path' will provide some insight to others....I am just starting!

Regards,

Mike
 
Mike,

I'm glad to hear your appointment went well, and you received clarification on information which made you feel better. It's a good idea that you will get copies of your records.

It's good to hear the doc is on your side, and welling to help.

My doc did the same as your doc: MEB was mentioned, but really wasn't considered until after I received the necessary surgeries, and treatment. When my health did not improve, the MEB was initiated.

I hope all goes well with everything for you. I'm sure your information will provide great insight for forum members.

Good luck on your journey.
 
Thanks Purple!

I was pleasantly surprised in the appointment. It was very reassuring to chat and discuss things in an open way. I also let him know that I have been learning about the whole process, he actually encouraged me to get as knowledgeable as possible...if anything it eliminates the stress of the unknown.

Mike:)
 
Sorry to chime in late on this thread.

In addition to everything previous, if you ever notice someone's info in your medical records you need to bring it to the attention of your MTFs privacy officer.

1) info needs to get into correct record (it may be significant to other persons treatment)

2) MTF has the responsibility of notifying the other party that thier protected health informaiton was disclosed (info shouldn't be in your record, but once you read it the MTF has a HIPAA violation that must be acted on).
 
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