IN THE CASE OF:  
 
  BOARD DATE: 5 September 2023 
 
  DOCKET NUMBER: AR20230001967 
 
 
APPLICANT REQUESTS:  in effect, correction of his DA Form 3349 (Medical  
Condition – Physical Profile Record), dated 17 March 1971, to show sprain of the right ankle in lieu of sprain of the left ankle. 
 
APPLICANT'S SUPPORTING DOCUMENT(S) CONSIDERED BY THE BOARD: 
 
• DD Form 149 (Application for Correction of Military Record) 

• DD Form 214 (Report of Separation for Active Duty) 

• DA Form 3349 

• photograph 


 
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 the medical report says left ankle injured when indeed it was his right ankle in Vietnam. After filing for disability, claim was denied because report indicates left ankle not right ankle.   
 
3.  The applicant underwent a medical examination for induction on 15 April 1968. The Standard Form (SF) 88 (Report of Medical Examination) shows he was found qualified for service and assigned a physical profile of 111121.   
 
A physical profile, as reflected on a DA Form 3349 (Physical Profile) or SF 88, is derived using six body systems: "P" = physical capacity or stamina; "U" = upper extremities; "L" = lower extremities; "H" = hearing; "E" = eyes; and "S" = psychiatric (abbreviated as PULHES). Each body system has a numerical designation: 1 meaning a high level of fitness; 2 indicates some activity limitations are warranted, 3 reflects significant limitations, and 4 reflects one or more medical conditions of such a severity that performance of military duties must be drastically limited. Physical profile ratings can be either permanent or temporary. 
4.  The applicant was inducted in the Army of the United States on 7 April 1969. He was discharged on 9 April 1969. He enlisted in the Regular Army on 10 April 1969.  
 
5.  The applicant underwent a medical examination for separation on 11 November 1971. The SF 88 shows he was found qualified for separation and assigned a physical profile of 111111.  
 
6.  A DA Form 664 (Serviceman’s Statement Concerning Application for Compensation from the Veterans Administration), dated 11 November 1971, shows the applicant indicated he had filed an application for compensation.   
 
7.  The applicant was honorably released from active duty and transferred to the Ready Reserve on 11 November 1971.  
 
8.  The applicant provided: 
 
 a.  A DA Form 3349 showing he was issued a temporary physical profile of 11T3111 for sprain of the left ankle effective 17 March 1971 with an expiration of 17 April 1971.   
 
 b.  A photograph of a Soldier (presumably the applicant) with his right lower leg in a cast. The photograph is not dated. 
 
9.  MEDICAL REVIEW: 
 
    a.  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:   
    b.  The applicant is applying to the ABCMR requesting a reconsideration of a change in his Soldier treatment record or STR.  He states: “Medical report says left ankle injured when indeed it was my right ankle.  In Vietnam.”  
    c.  The Record of Proceedings details the applicant’s military service and the circumstances of the case.  His DD 214 shows he entered the regular Army on 10 April 1969 and received an honorable discharge on 11 November 1971 under the provisions provided Section VII, Chapter 5 of AR 635-200, Personnel Management – Enlisted Personnel (1 June 1967): Early Separation of Overseas Returnees.  The separation 
program number (SPN or “spin code”) of 411 denotes “Early separation of overseas returnee.”    
    d.  A Physical Profile dated 17 March 1971 states “Sprain of left ankle.”  The temporary profile placed the applicant on limited field duties for one month.  A photograph shows a Vietnam era Soldier with a short leg walking cast on his right leg. 
    e.  The applicant completed his pre-separation medical evaluation on 11 November 1971.  On his Report of Medical Examination, he noted his health as good, the provider documented a normal examination, no defects or diagnoses, and found the applicant qualified for separation. 
    f.  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.     
    g.  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. 
    h.  It is recommended the applicant address this issue as provided for by 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 applicant’s contentions, the military record, and regulatory guidance were carefully considered. Medical records reflect the observations and opinions of medical professionals at the time they were created. Alteration of a diagnosis in those records after the fact may lead to fundamental questions about the veracity of the records in this case and in general. 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. 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. It is recommended the applicant address this issue as provided for by HIPAA. For these reasons, it would not be proper for the Board to change any of the medical documents the applicant provides which would, in effect, alter his diagnosis in the medical records. 
 
BOARD VOTE: 
 
Mbr 1 Mbr 2 Mbr 3 
 
: : : GRANT FULL RELIEF 
 
: : : GRANT PARTIAL RELIEF 
 
: : : GRANT FORMAL HEARING 
 
xx: xx: xx: 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. 
 
  9/5/2023

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 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 40-403 (Medical Service Health Records), in effect at the time of the applicant's active service, established the health record in the Army, and include instructions for its preparation, maintenance, and disposition. It states: 
 
 a.  The primary purpose of the record is to insure that information of value in the medical care of an individual is constantly available to medical service personnel, except, of course, during active combat. The health record is designed to minimize repetition of diagnostic procedures, and to reduce correspondence to obtain records of previous treatment. 
 
 b.  It will assist medical officers in advising commanders concerning the retention and utilization of personnel. Similarly, the record will be of interest to physical evaluation boards appraising the physical fitness or eligibility for benefits of members of the Army. The record will serve such other purposes as facilitating the adjudication of claims and providing an important source of medical research data. 
 
 c. Section III, states: 
 
  (1)  Entries in health record forms – responsibility: The health record is normally in custody of medical and dental officers; responsibility for insuring that information is promptly and accurately entered in health record forms rests with these custodians. 
 
  (2)  Entries will be made in health record forms at the time a patient is seen or at the time an included document is received. ·While certain minimum standards of content for varying entries are prescribed in these regulations, the essential criterion which should guide physicians and dentists adding information to the health record is that entries must be useful to those studying the record in the future. An entry in the health record is a communication of all relevant information to other physicians or dentists; its adequacy should be appraised in this light. 
 
  (3)  Whenever a change is required in the health record, or an erroneous entry is discovered, a single ink line will be drawn through the entry without destroying its legibility and the correct entry will be made. All such changes will be initialed and dated. 
 
3.  Section 1556 of Title 10, USC, 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//