I recently had a
physician who performs C&P Exams
for VA Disability
ask about the best,
fastest way to write a patient’s medical history.
This is an excellent
question. Physicians on the whole spend an immense amount of time writing their
reports, sometimes more time than they spend with the patient. This is because
it is often very important for things to be recorded correctly, especially when
it comes to disability. But is this really the best use of their time? Are
there ways to speed up the recording process so physicians are free to spend
more time with their patients?
Recording a patient’s
medical history in a C&P Exam is important, but can be incredibly time-consuming.
There are certain things that the VA must know in order to determine a case
correctly. If information is missing, they’ll either misjudge the case or send
it back for the missing info (thus causing a significant delay in the
Now, it is true that
the medical history on the C&P Exam is not the only evidence that should
accompany a claim. In fact, it can’t be. Service treatment records (STRs) are
the legally required proof that every claim must have. However, a good summary
of the necessary information recorded by the physician performing the C&P
Exam can actually make the processing time speed up since the Rating Authority
won’t have to dig so hard for the pertinent info. They’ll read it, find it quickly
in the STRs, and done. No having to scrutinize every single STR submitted. The
Rating Authority is also much more happy (a really good thing—you want the
people deciding your future to do it in a good mood, believe me). Going through
a ton of paperwork stinks.
Veterans, it is good
for you to know these tips because, let’s face it, not all of your physicians
will read this blog. By knowing what to record, you can make sure it happens.
This is your disability, after all, and so it is ultimately your responsibility
that it’s done correctly. This does not give you permission, however, to
condescend or disrespect your physician. Please be careful how you talk to your
doctor. You want them on your side. That being said, you have the right to get
it done right.
So, we’ve established
that it’s good to have a quality medical history, but quality doesn’t mean it
has to be long and take forever to write. In order to save the physician a
great deal of time, speed up a claim’s processing time, and create a happy
Rating Authority, here are two quick tips to writing a medical history.
1. Establish service-connection. The number one most important thing to
record in the medical history is how the condition is service-connected. The VA can only compensate conditions that
are service-connected, and so whatever information is needed to prove
service-connection is essential. If the condition was acquired or diagnosed
while the vet was on active duty, then just draw attention to this fact in the
history. If, however, the condition was not acquired during service, but is
caused by another service-connected condition, then this relationship is
essential to highlight.
The amount of information for this does not have to be large, just
quality. A single sentence may be enough: "The veteran first broke his
tibia during exercises while on active duty on November 14th, 2004" or
"While in the military, the veteran was diagnosed with pulmonary
tuberculosis. The veteran was separated from the military July 21st, 2006. On
March 15th, 2007 he was diagnosed with interstitial lung disease secondary to
his service-connected pulmonary tuberculosis." The last example was weak medically,
but the point should be clear. Establishing service-connection is essential,
but short and sweet is totally fine.
2. Record the Rating Criteria. After service-connection is established,
the only other things that matter are the details that are essential for rating
the condition. Every single doctor's visit or exacerbating event isn't
necessary. The Rating Authorities will have access to all these medical
records, so everything does not have to be reproduced. Since the VA will mostly
use the information recorded in the C&P Exam to rate the condition, the
only additional history that must be recorded is details that will
assist or are pertinent to the ratings. This exact information will be
different for every condition, but guess what?! There’s a website for that: www.MilitaryDisabilityMadeEasy.com. Just look up the condition, figure out what
is necessary to rate it, and make sure it’s included in the history.
For example, aplastic anemia, code 7716, is rated on the regularity of transfusions or
infections. In this case, the one-time C&P Exam data won't be as important
as the history of the frequency of transfusions or infections. The history
should then clearly note that "the veteran has a history of receiving
transfusions once every 3 months," etc. That is how the condition is
rated, so that is the important information to include in the history. And
that's all that needs to be included. The rest does not matter since it
isn't pertinent to the ratings.
Another example, let's say a veteran acquired a knee injury while on
active duty. At the C&P Exam, he only displayed limited motion, but he has a history of instability with frequent
majority of knee conditions are rated on limited motion, and in most cases,
only one rating can be given for a knee condition. In this case, however, the
history of instability is essential to include in the history because
instability CAN be rated in addition to limited motion. It is the only knee
code that can be given in addition to other knee ratings. Thus, the history of
instability is definitely essential to record. It is not essential, however, to
list every range of motion exam he ever had since the VA only cares what his range
of motion is right now (the C&P Exam).
So, there you have it.
Two tips to writing a quality, fast medical history for a C&P Exam.
The more you start
thinking as a rater, and thus figuring out what is needed to rate the
condition, the more you'll [hopefully] be able to speed up the time it takes to
write your histories, only spending time on the pertinent info and skipping all
the rest. When in doubt, however, it is probably best to include it than