RECORD OF PROCEEDINGS
AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS.

IN THE MATTER OF:			DOCKET NUMBER:  BC-2015-01761

  						COUNSEL:  NONE

						HEARING DESIRED:  NO


APPLICANT REQUESTS THAT:

A medical note in his electronic record in the Armed Forces 
Health Longitudinal Technology Application (AHLTA), dated 16 Apr 
08, which reflects “Pt's symptoms likely due to excessive etoh 
consumption.  Pt counselled to cut back and not drink until 
consultation with cardiologist...” be removed and replaced with 
“Pt counselled to not consume etoh until consultation with 
cardiologist.”  


APPLICANT CONTENDS THAT:

His medical record was never properly updated to clarify that 
“excessive etoh consumption” was not the cause for his initial 
medical symptoms.  A definitive diagnosis was provided by two 
cardiologists stating that his symptoms were caused by 
tachycardia.  This incorrect information has been flagged as 
potential disqualifying information during medical record 
reviews and has impacted his selection for jobs and insurance.

The applicant’s complete submission, with attachments, is at 
Exhibit A.


STATEMENT OF FACTS:

The applicant is currently serving on active duty in the Regular 
Air Force in the grade of Lieutenant Colonel with a Date of Rank 
of 1 Aug 14.  

Based on information provided by the applicant, as of 16 Apr 08, 
his AHLTA record reflects the following statement, “RHYTHM 
DISORDER: Pt’s symptoms likely due to excessive etoh 
consumption.  Pt counselled to cut back and not drink until 
consultation with cardiologist….”






AIR FORCE EVALUATION:

AFMOA/SGH recommends granting the applicant’s request to change 
the note in AHLTA to reflect, “RHYTHM DISORDER: Pt counselled to 
not consume alcohol until consultation with cardiologist.”  

AFMOA notes the Cardiology Consultation with the Cardiovascular 
Center of Lompoc, Inc., dated 18 Apr 08 indicates “The patient 
had routine laboratory work and also drug and alcohol screens, 
which were negative.”  Medical note from Arrhythmia Consultants 
of the Central Coast, dated 17 Oct 12 states that, alcohol was 
not the cause of the applicant’s arrhythmia and indeed is not 
known to ever be the cause of this type of arrhythmia, and that 
he has had no recurrence of arrhythmia since ablation and is 
considered cured.  In Accordance With (IAW) AFI 41-210, TRICARE 
Operations and Patient Administration Functions, Section 5.3., 
Correcting Health Records, for correction to remove the 
erroneous data from the applicant’ electronic health record will 
be submitted to the Clinical Information Services for the Air 
Force to be forwarded to Defense Health Information Management 
System (DHIMS) Program Office for action.  

A complete copy of the SGH evaluation is at Exhibit C.


APPLICANT'S REVIEW OF AIR FORCE EVALUATION:

The applicant indicates that he made several attempts to have 
his AHLTA record administratively corrected; however, he was 
unsuccessful in each attempt.

The applicant’s complete response, with attachments, is at 
Exhibit E.


THE BOARD CONCLUDES THAT:

1.  The applicant has exhausted all remedies provided by 
existing law or regulations.

2.  The application was timely filed.

3.  Sufficient relevant evidence has been presented to 
demonstrate the existence of an error or injustice.  We took 
notice of the applicant's complete submission in judging the 
merits of the case and agree with the opinion and recommendation 
of the Air Force Medical Operations Agency and adopt its 
rationale as the basis for our conclusion the applicant has been 
the victim of an error or injustice.  While we note the comments 
of the Air Force OPR indicating there is an administrative 
avenue of relief available for the applicant to pursue the 
requested correction of his records, in the interests of 
administrative economy and in view of the comments by the 
applicant indicating that he has attempted to pursue said relief 
administratively without success, we believe it appropriate to 
grant the requested relief.  Therefore, we recommend the 
applicant's records be corrected as indicated below.	


THE BOARD RECOMMENDS THAT:

The pertinent military records of the Department of the Air 
Force relating to the APPLICANT be corrected to show that a 
medical note in his electronic record in the Armed Forces Health 
Longitudinal Technology Application (AHLTA), dated 16 April 
2008, reflects “RHYTHM DISORDER: Pt counselled to not consume 
alcohol until consultation with cardiologist” rather than “Pt's 
symptoms likely due to excessive ETOH consumption.  Pt 
counselled to cut back and not drink until consultation with 
cardiologist...”


The following members of the Board considered AFBCMR Docket 
Number BC-2015-01761 in Executive Session on 15 Mar 16 under the 
provisions of AFI 36-2603:

	, Panel Chair
	, Member
	, Member

All members voted to correct the records as recommended.  The 
following documentary evidence was considered:

	Exhibit A.  DD Form 149, dated 16 Apr 15, w/atchs.
	Exhibit B.  Excerpts from Medical/Personnel Records.
	Exhibit C.  Letter, AFMOA/SGH, undated.
	Exhibit D.  Letter, AFBCMR, dated 1 Feb 16.
	Exhibit E.  Letter, Applicant, dated 18 Feb 16.










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