ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS BOARD DATE: 18 September 2019 DOCKET NUMBER: AR20170014441 APPLICANT REQUESTS: correction of DD Form 602 (Patient Evacuation Tag) to show battle casualty. APPLICANT'S SUPPORTING DOCUMENTS CONSIDERED BY THE BOARD: * DD Form 149 (Application for Correction of Military Record) * DD Form 602 (Patient Evacuation Tag) * Clinical Record Cover Sheet * Clinical Record * Physical Profile Record * Line of Duty Status Determination FACTS: 1. The applicant did not file within the three year time frame provided in Title 10, United States Code (USC), section 1552 (b); however, the Army Board for Correction of Military Records conducted a substantive review of this case and determined it is in the interest of justice to excuse the applicant's failure to timely file. 2. The applicant states that you can see on the form DD Form 602 that his injury was originally checked as "battle casualty" then for some reason it was changed to "disease" and he doesn’t know why. All three hospitals that he visited showed that he had a skull fracture behind his left ear. He states skull fractures are not caused by a disease. 3. The applicant provides: a. DD Form 602, dated 18 September 1968, which states the applicant was diagnosed with subarachnoid hemorrhage, that was classified as a disease, and treated with 6 milligrams of codeine. b. Clinical Record Cover Sheet, dated 8 September 1968, which states he was diagnosed with a fracture of the left occipital linear skull, and a hematoma, of the right inter-cerebral. On 8 October 1968, he was transferred to Walter Reed General Hospital in Washington, DC. c. Clinical Record, dated 30 September 1968, which states that he suffered from frequent headaches on the right side, and was hospitalized where numerous lumbar punctures which revealed bloody spinal fluid with no localizing neurological signs d. Physical Profile Record, dated 22 November 1968, which states that the applicant was diagnosed with a fracture of the left occipital linear skull, and a hematoma of the right frontal inter-cerebral. e. Line of Duty Status Determination, dated 17 October 1968, which states the Department of the Army authorized a special procedure for hostile action areas which defers determination of favorable LOD investigations, for his injury sustained on 8 September 1968. 4. A review of the applicant’s service records shows the following: a. He was inducted into the Army of the United States on 30 August 1967. He served in Vietnam from 18 August 1968 to 9 October 1968. b. His DA Form 20 (Enlisted Qualification Record), illustrates in item 40 (Wounds) he suffered from a left occipital linear skull fracture, documented 8 September 1968. c. On 8 September 1968, he was diagnosed with a fracture of the left occipital linear skull, and a hematoma, of the right inter-cerebral. On 8 October 1968, he was transferred to Walter Reed General Hospital in Washington, DC. d. A casualty message dated 12 September 1968 indicated the applicant was placed on the SI (seriously wounded, injured, or ill) at the 2d Surgical Hospital on 11 September 1968 due to a vascular malformation of the brain possibly due to a subarachnoid hemorrhage. The message indicates he had been hospitalized on 8 September 1968. e. By Western Union telegram dated 12 September 1968, the applicant's parents were informed that he had been placed on the seriously ill list on 11 September 1968 as the result of vascular malformation of the brain possibly due to subarachnoid hemorrhage. This was the proper notification procedure for injuries at the time. f. His clinical record narrative summary, dated 9 October 1968, states that he suffered from frequent headaches on the right side, and was hospitalized where numerous lumbar punctures which revealed bloody spinal fluid with no localizing neurological signs. g. He was honorably transferred to the United States Army Reserve (USAR) on 9 June 1969, under the provisions of Army Regulation 635-200 (Personnel Separations – Enlisted Personnel), for early separation to attend school. He had 1 year 9 months, and 10 days of active service. h. On 1 August 1973, he was honorably discharged from the USAR under the provisions of AR 135-178 (Enlisted Administrative Separations), for expiration of terms of service. i. There was no record of a DD Form 602 in the applicant’s record. 5. His name is not shown on The Adjutant General's Office Casualty Division Casualty Reference Name Listing, a list of Vietnam era casualties commonly used to verify entitlement to award of the PH. 6. He applied to ABCMR on 9 March 2005, the Board denied his request for a Purple Heart and Board determined that the evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined that the overall merits of this case are insufficient as a basis for correction of the records 7. By regulation, the information entered on the medical records by the medical provider or treating physician reflects the conditions as they existed at the time they occurred or shortly thereafter. 8. By regulation, only documents prepared by authorized U.S. Army Medical Department (AMEDD) personnel will be filed in Army medical records. This restriction does not prohibit the use of other documents created by attending physicians and dentists outside AMEDD (Navy, Air Force, civilian, and so forth) or the filing of other documents as summaries or brief extracts. If such documents are filed, their source and the physician or dentist under whom they were prepared must be identified. 9. By regulation (AR 600-200), a brief description of wounds or injuries (including injury from gas) requiring medical treatment received through hostile or enemy action, including those requiring hospitalization should be entered into item 40 (Wounds) of the DA Form 20 (Enlisted Qualification Record). 10. By regulation, AR 638-8, during wartime, units will report all casualties found on the battlefield to include American civilians, DOD or DA Civilians, contractors, and personnel of other Services. Units will document casualties that result from contingency operations. 11. DD Form 602’s were prepared for each patient to be moved by a military common carrier and is the patient's in transit medical record. The attending physician prescribes en-route medical requirements on this form before the patient departs the originating facility and all en-route treatments are noted on the form during the patient's journey. BOARD DISCUSSION: After reviewing the application and all supporting documents, the Board found some relief was warranted. The applicant’s contentions were carefully considered. Based upon the preponderance of the evidence, the Board agreed “Injury” should have been checked instead of “Disease.” Based upon the documentary evidence provided by the applicant and found within the military service record, the Board concluded the DD Form 602 was correct by not showing the injury was a battle casualty. BOARD VOTE: Mbr 1 Mbr 2 Mbr 3 : : : GRANT FULL RELIEF :X :X :X GRANT PARTIAL RELIEF : : : GRANT FORMAL HEARING : : : DENY APPLICATION BOARD DETERMINATION/RECOMMENDATION: 1. The Board determined the evidence presented is sufficient to warrant a recommendation for partial relief. As a result, the Board recommends that all Department of the Army records of the individual concerned be corrected by amending the DD Form 602, dated 18 September 1968 to showing a check was placed in the box for “Injury.” 2. The Board further determined the evidence presented is insufficient to warrant a portion of the requested relief. As a result, the Board recommends denial of so much of the application that pertains to amending the form to show “Battle Casualty.” I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case. REFERENCES: 1. Title 10, USC, section 1552(b), provides that applications for correction of military records must be filed within three years after discovery of the alleged error or injustice. This provision of law also allows the Army Board for Correction of Military Records (ABCMR) to excuse an applicant's failure to timely file within the three-year statute of limitations if the ABCMR determines it would be in the interest of justice to do so. 2. Army Regulation (AR) 40-66 (Medical Record Administration and Healthcare Documentation), currently in effect, prescribes policies for preparing and using medical reports and records for Soldiers receiving medical treatment or evaluation in an Army military treatment facility. Paragraph 3-12 (Recording Injuries) states the same details will be given and the same terms used when both battle and non-battle injuries are recorded. To be complete, record on DA Form 3647 and the recording of an injury must include the details of the nature of the injury, the part or parts of the body affected, the external causative agent, how the injury occurred, whether the injury was self- inflicted, the location where the person was injured, and the date of the injury. a. Chapter 3 (Preparation of Medical Records) states that unless authorized by this regulation, only documents prepared by authorized U.S. Army Medical Department (AMEDD) personnel will be filed in Army medical records. This restriction does not prohibit the use of other documents created by attending physicians and dentists outside AMEDD (Navy, Air Force, civilian, and so forth) or the filing of other documents as summaries or brief extracts. If such documents are filed, their source and the physician or dentist under whom they were prepared must be identified. b. Medical record entries will be made in all inpatient, outpatient, service treatment, dental, Army Substance Abuse Program, and occupational health records by the healthcare provider who observes, treats, or cares for the patient at the time of observation, treatment or care. No healthcare practitioner is permitted to complete the documentation for a medical record on a patient unfamiliar to him or her. In unusual extenuating circumstances (for example, death of a provider), local policy will ensure that all means have been exhausted to complete the record. 3. AR 638-8 (Casualty and Mortuary Affairs - Army Casualty Program), prescribes the policies and mandates responsibilities, operating tasks, and procedures for the Army Casualty Program. Casualty operations include casualty reporting, casualty notification, assisting Family members and beneficiaries with any associated benefits and entitlements, and working in conjunction with the Army Mortuary Affairs Program. //NOTHING FOLLOWS// ABCMR Record of Proceedings (cont) AR20170014441 5 1