Question about my recent medical record with the VA.

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#1
Hello,

I started going to the VA about a year ago now, and recently found out about the blue button medical report option on the myhealthevet site, which can give a summary or pretty thorough pdf file of my recent visitations. I was looking at my medical reports and noticed that on my most recent visit, Jan 8th, my primary care physician input in the notes section that I had 2019 ICD-10-CM Diagnosis Code F43.21; which is adjustment disorder with a depressed mood. Now this caught me completely off guard, because I have never had thoughts of depression, nor have I ever discussed anything related to them. My appointment was for a routine check-up and about me wanting to discontinue two medications for headaches that I no longer needed after changing up my diet. I messaged my pcp yesterday through the myhealthevet site, and his response about the input was that during one of my first appointments the RN screened and flagged me for depression. The only time I was ever asked was my very first appointment with the VA, and that was while I had a foot injury. I told the RN that the only thing I was upset about was that my foot injury was impacting my daily work life and such. Nothing more, nothing less. That's crazy to me that from that small moment they flag me for any kind of disorder or depression. My concern with this is that when I get to the medical portion of the process that they will see the Jan 8th notes first, and immediately DQ me without any kind of information to it. I have never been on any anxiety or mental health related medications, nor were they ever suggested. Am I overthinking this, or should I be concerned? I am in the process of trying to see what my pcp thinks / can do about it, but so far all they have said is that they can add an addendum stating that I am no longer having those problems. My obvious issue with that is that it still gives the notion that I had them in the first place, which I did not.
-The reason I was looking through my medical report was to see if it was a complete record or only for my recent timeline that I have been attending the VA clinic here. I am just trying to square away all of my stuff before my appointments so that I have them ready to go if they are needed. Any input is appreciated.
 

Foogy

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#2
Your PCP can remove it fairly easily, you have a right to amend any diagnosis if you believe it to be wrong or incorrect. It just needs to be done by your PCP. If you were checking out the MyHealthEVet website,it's full of errors. Ask to get it amended.
 

Foogy

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#3
Whether it will have an impact on your medical, only the flight surgeon can tell, as they're the only qualified ones and it changes with each one.
 

MJ

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#5
If it's not changed you could be TierII'd. They don't just trash an applicant because of a potential problem. And what the VA did is not a diagnosis, so it may have zero impact, but worst case, you'll have to prove you don't have it. Also, if you've accepted a TOL and they started processing it, they've already requested your medical records.
 
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#8
My pcp got back to me today and stated that they removed anything related to the adjustment disorder and depression from my record, but of course I went and looked and immediately it still shows up among my recent visitation notes. It looks like all they did was add an addendum, which may be all they are allowed to do at the VA? This is what shows up immediately on my recent notes after he changed them; Active problems - Depression (SCT 35489007) among my foot pain from the past and headaches. Only until I scrolled down a good 3 pages did I find this entry;
"01/11/2019 ADDENDUM STATUS: COMPLETED
Recent calls and review by the patient indicated no signs of depression and this
has been recorded at the chart. Depression screening results do not apply
currently and patient does not have depression."
My obvious issue with this is that it still flags depression. The first thing that is seen is the active problems, which does not state anything about an addendum until scrolling down 3 pages. Does anyone know if I can specifically ask that they remove all of it and not just add an addendum? Like I said before; if I had an actual issue I would not care, but i'm being flagged as screening positive for depression based on saying I was upset about a foot injury last year.
 
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MJ

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#9
It quite clearly says depression isn't an issue and never was. They may not be allowed to delete it. Go see a patient advocate if you're that worried.
 

Foogy

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#10
Either way when medical goes through it they'll see that addendum. They may go through a lot of people but they fine comb every one of us.
 
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