IN THE CASE OF: BOARD DATE: 17 February 2023 DOCKET NUMBER: AR20220007574 APPLICANT REQUESTS: amendment of his service treatment records to reflect a right wrist sprain in lieu of right wrist contusion on 13 November 1979. APPLICANT'S SUPPORTING DOCUMENT(S) CONSIDERED BY THE BOARD: * multiple DD Forms 149 (Application for Correction of Military Record) * two letters from the Army Review Boards Agency (ARBA) * Standard Form 93 (Report of Medical History), 2 June 1978 * Partial Standard Form 88, 2 June 1978 * service treatment record, 23 March and 2 April 1979 * service treatment record, 13 November 1979 * Radiographic Report, 13 November 1979 * Board of Veterans’ Appeals Order, 12 March 2019 * Compensation and Pension (C&P) Examination Note, 29 January 2021 * Department of Veterans Affairs (VA) Form 21-4138 (Statement in Support of Claim), 28 March 2022 FACTS: 1. The applicant did not file within the 3-year time frame provided in Title 10, U.S. Code, section 1552(b); however, the Army Board for Correction of Military Records (ABCMR) 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: a. He served in the Army from 14 June 1978 through 11 June 1981. During this time, he incurred an injury to his right hand while performing his duties. On 13 November 1979, a battery from a 2 1/2 ton truck fell on his right hand, smashing it. b. He reported the injury and went to sick call where he had an x-ray done, after which he was diagnosed with a right wrist sprain. This diagnosis was either missed or incorrectly documented in his service treatment records as a right hand contusion, which is incorrect. He had a right wrist sprain. c. In his VA Form 21-4138, the applicant relays that the x-rays done on the day of the injury show no acute fracture; it doesn’t state contusion. It states small amount of swelling on anterior hand; no open lesions. He was given an ace bandage wrap and an ice pack and put on light duty for 3-4 days with no lifting. As a 76P (Material Supply Clerk), he always handled parts and equipment to stock inventory and this accident effected his work. He has developed carpal tunnel syndrome in his right hand related to this injury and has twice had surgery to his right hand and elbow, reflected in his VA medical records. d. Please take a look at this error and correct it. This misdiagnosis in his service medical records has caused him to be denied VA benefits related for what is a service- connected injury due to right wrist sprain. 3. The applicant provided a Standard Form 93, dated 2 June 1978, wherein he provided his medical history for the purpose of Regular Army enlistment and indicated having had a prior head injury and sprained ankle. 4. He also provided page 1 of a Standard Form 88, likewise dated 2 June 1978, which shows the applicant underwent medical examination on the date of the form for the purpose of Regular Army enlistment. The examiner’s notes reference hernia repair in June 1977 and pes planus. 5. The applicant enlisted in the Regular Army on 15 June 1978 and was awarded the Military Occupational Specialty (MOS) 76P. 6. The applicant provided a service treatment record containing two notes, as follows: a. The first note shows the applicant was seen at the Combined Unit Dispensary on 23 March 1979 for complaints of pain in the right eye for the past week and that he did not know what happened to his eye. His eye was red and he was assessed with conjunctival hematoma and given Neosporin. b. The second note shows the applicant was seen at the Combined Unit Dispensary on 2 April 1979 after jamming his left thumb while playing basketball. His finger got bent backward, resulting in swelling, limited range of motion, and stiffness. Refer to x-ray film. No fracture noted. He was assessed with a sprain of the metacarpophalangeal (MP) joint of his left thumb and his thumb was splinted. 7. A second service treatment record shows the applicant was seen at the Combined Unit Dispensary on 13 November 1979, after a vehicle battery fell onto the posterior of his right hand, smashing it. There was a small amount of swelling on the anterior hand, no open lesions. The small finger had an enlarged area between the 2nd and 3rd. metacarpals. 8. A Radiographic Report shows an x-ray was taken of the applicant’s right hand on 13 November 1979, after it was smashed with a battery. The report shows no acute fracture. He was assessed with a contusion and was to use ice for treatment. 9. A Standard Form 93, dated 23 April 1981, shows the applicant provided his medical history in conjunction with an examination on the date of the form for the purpose of expiration term of service discharge. He does not indicate hand injury on the form. The corresponding medical examination is not in his available records for review. 10. The applicant’s DD Form 214 (Certificate of Release or Discharge from Active Duty) shows he was honorably released from active duty on 11 June 1981, after 2 years, 11 months, and 27 days of net active service and transferred to the U.S. Army Reserve Control Group (Reinforcement). 11. A Board of Veterans’ Appeals Order, dated 12 March 2019, shows the applicant’s entitlement to service connection for his right knee disability and right hand disability are denied as the preponderance of the evidence of record does not reflect these disabilities were related to any disease or injury incurred during active service. 12. The applicant provided a 23-page VA C&P Examination Note, dated 29 January 2021, regarding his knees and lower legs which has been provided in full to the Board for review. 13. MEDICAL REVIEW: The Army Review Boards Agency (ARBA) Medical Advisor was asked to review this case. Documentation reviewed included the applicant’s ABCMR application and accompanying documentation, the military electronic medical record (AHLTA), the VA electronic medical record (JLV), the electronic Physical Evaluation Board (ePEB), the Medical Electronic Data Care History and Readiness Tracking (MEDCHART) application, and/or the Interactive Personnel Electronic Records Management System (iPERMS). The ARBA Medical Advisor made the following findings and recommendations: a. The applicant is applying to the ABCMR requesting correction to a medical record. He states: “While serving in the US Army from 14 June 1978 ‘til 11 June 1981, I experienced an injury to my right hand while performing my duties. On 13 November 1979, I had a 2 ½ truck battery fall and smash my right hand. Wen to sick call and diagnosed with a right wrist sprain. Had x-ray done. Missed or incorrect diagnosis in 201-file STR {Service Treatment Record} states I had a right had contusion which is incorrect: I had a right wrist sprain ... Please look at this and understand it is not correct.” b. The Record of Proceedings details the applicant’s military service and the circumstances of the case. His DD 214 for the period of Service under consideration shows he entered the regular Army on 15 June 1978 and was honorably discharged on 11 June 1981 under provisions provided in paragraph 5-12 of AR 635-200, Personnel Management (1 March 1978): Short length of time remaining on active duty precludes reassignment. c. A handwritten military clinical encounter dated 13 November 1979 shows the applicant was diagnosed with contusion (bruising) of the right hand after evaluation for a battery falling on the back of the right hand. The radiologist’s report on the plain radiographs of the right hand taken that day reported “No acute fracture.” d. The applicant did not report this injury on his pre-separation Report of Medical History. No evidence of a right wrist sprain was identified in the case file, and it is unlikely such evidence would support his current claim of service connected right carpal tunnel syndrome. e. The Privacy Rule, part of the Health Insurance Portability and Accountability Act (HIPAA), gives patients, with few exceptions, the right to inspect, review, and receive a copy of their medical records and billing records that are held by health plans and health care providers covered by the Privacy Rule. This includes the ability to request corrections or amendments to these records when a patient believes information in their medical or billing record is incorrect. f. The Privacy Rule provides individuals with this right to have their protected health information (PHI) amended in a manner that is fully consistent with the Correction Principle in the Privacy and Security Framework (See 45 C.F.R. § 164.526). The health care provider or health plan must respond to this request, and if it created the information, it must amend inaccurate or incomplete information. If the provider or plan does not agree to the request, the patient has the right to submit a statement of disagreement that the provider or plan must add to the record. g. There is no evidence of error, and it is the recommendation of the ARBA medical advisor that if the applicant still seeks to correct his medical record, he utilize the process outlined in HIPAA. BOARD DISCUSSION: After reviewing the application, all supporting documents, and the evidence found within the military record, the Board found that relief was not warranted. The Board carefully considered the applicant's record of service, documents submitted in support of the petition and executed a comprehensive and standard review based on law, policy and regulation. Upon review of the applicant’s petition, available military records and the medical review the Board concurred with the advising official finding no evidence of error, and it is the recommendation that if the applicant still seeks to correct his medical record, he utilizes the process outlined in HIPAA. Based on the evidence in the record, the Board determined the applicant did not report this injury on his pre-separation Report of Medical History. In addition, there is no evidence of a right wrist sprain being identified in the case file. Based on this, the Board denied relief for amendment of the applicant’s service treatment records to reflect a right wrist sprain in lieu of right wrist contusion on 13 November 1979. BOARD VOTE: Mbr 1 Mbr 2 Mbr 3 : : : GRANT FULL RELIEF : : : GRANT PARTIAL RELIEF : : : GRANT FORMAL HEARING X X X DENY APPLICATION ? BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined the overall merits of this case are insufficient as a basis for correction of the records of the individual concerned. 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, U.S. Code, section 1552(b), provides that applications for correction of military records must be filed within 3 years after discovery of the alleged error or injustice. This provision of law also allows the ABCMR to excuse an applicant's failure to timely file within the 3-year statute of limitations if the ABCMR determines it would be in the interest of justice to do so. 2. Army Regulation 40-66 (Medical Record Administration and Healthcare Documentation) prescribes policies for preparing and using medical reports and records for Soldiers receiving medical treatment or evaluation in an Army military treatment facility. a. Paragraph 1-6 pertains to medical record ownership. It states Army medical records are the property of the Government. Thus, the same controls that apply to other Government documents apply to Army medical records. Army medical records, other than those of Reserve Components, will remain in the custody of the Medical Treatment Facilities at all times. Reserve Component records will remain in the custody of the appointed Service Treatment Record custodian. The Armed Forces Health Longitudinal Technology Application (AHLTA) record will remain in the custody of the U.S. Army Medical Department (AMEDD) and Department of Defense via electronic storage, and hardcopy of the treatment records will be retried to the National Personnel Records Center in accordance with the records dispositions schedule in Army Regulation 25- 400-2 (The Army Records Information Management System (ARIMS). b. Chapter 3 (Preparation of Medical Records) states that unless authorized by this regulation, only documents prepared by authorized 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. c. 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. Title 10, U.S. Code, section 1556 requires the Secretary of the Army to ensure that an applicant seeking corrective action by the Army Review Boards Agency (ARBA) be provided with a copy of any correspondence and communications (including summaries of verbal communications) to or from the Agency with anyone outside the Agency that directly pertains to or has material effect on the applicant's case, except as authorized by statute. ARBA medical advisory opinions and reviews are authored by ARBA civilian and military medical and behavioral health professionals and are therefore internal agency work product. Accordingly, ARBA does not routinely provide copies of ARBA Medical Office recommendations, opinions (including advisory opinions), and reviews to Army Board for Correction of Military Records applicants (and/or their counsel) prior to adjudication. //NOTHING FOLLOWS// ABCMR Record of Proceedings (cont) AR20220007574 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1