BOARD DATE:	  30 April 2015

		DOCKET NUMBER:  AR20150005844 


THE BOARD CONSIDERED THE FOLLOWING EVIDENCE:

1.  Application for correction of military records (with supporting documents provided, if any).

2.  Military Personnel Records and advisory opinions (if any).


THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE:

1.  The applicant requests correction of his medical records to show he suffered from post-traumatic stress disorder (PTSD) as a result of military sexual trauma (MST). 

2.  The applicant states his first sergeant refused to enter his MST on his medical records at the time of the assault because that would have made him look bad.  He (the applicant) is now suffering from debilitating symptoms (nightmares, sweats, anger, anxiety, and loss of focus).  He is currently being treated with medications and will need prescriptions for the rest of his life.  His doctors say he will not be able to gain employment because of the loss of focus.  

3.  The applicant provides a statement from the Department of Veterans Affairs (VA). 

CONSIDERATION OF EVIDENCE:

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 Army Board for Correction of Military Records (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.  While it appears the applicant did not file within the time frame provided in the statute of limitations, the ABCMR has elected to conduct a substantive review of this case and, only to the extent relief, if any, is granted, has determined it is in the interest of justice to excuse the applicant's failure to timely file.  In all other respects, there are insufficient bases to waive the statute of limitations for timely filing.

2.  The applicant's records show he was inducted into the Army of the United States on 19 July 1966 and he held military occupational specialty 05C (Radio Operator).  He served in Korea from on or about 23 January 1967 to on or about 19 April 1968. 

3.  He was honorably released from active duty on 19 April 1968.  His DD Form 214 (Armed Forces of the United States Report of Transfer or Discharge) shows he completed 1 year, 9 months, and 1 day of active service. 

4.  His service medical records are not available for review with this case.  He provides a statement, dated 19 December 2014, from a VA staff psychiatrist who states the applicant has been under his care since October 2011.  He was diagnosed with PTSD which he (the psychiatrist) believes is due to trauma suffered during his military service.  He is now on multiple psychotropic medications to help alleviate his symptoms.  He continues to struggle with anxiety, anger, nightmares, and trouble focusing, due to his past traumatic experience.  He has received individual and group therapy for several months in the clinic and he needs ongoing follow-up for medications management and therapy. 

5.  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.  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.

DISCUSSION AND CONCLUSIONS:

1.  The applicant's service record does not contain his medical documents.  There is insufficient evidence to grant the applicant relief in this case.  

	a.  First, there is no evidence in the available records and the applicant provides none that confirms he suffered from PTSD as a result of MST at the time.  There are no police reports, investigation reports, journal entries, charge of quarters entries, or a treatment record that corroborates the applicant's contention. 

	b.  Second, although the VA staff psychiatrist diagnosed him with PTSD, nowhere on the VA staff psychiatrist's letter is the word "military sexual trauma" mentioned.  The applicant attributes his PTSD to MST but does not support that with any evidence.

	c.  Finally, the Army has an interest in maintaining the accuracy of its records for historical purposes.  The information in those records must reflect the conditions and circumstances that existed at the time the records were created.  In the absence of compelling information or evidence to the contrary, there is no basis for changing his medical records in this case.

2.  A copy of the VA psychiatrist's statement, along with his application will be filed in his official military personnel file.  This should serve to clarify any questions or confusion regarding his claim for PTSD as a result of MST. 

BOARD VOTE:

________  ________  ________  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 that the overall merits of this case are insufficient as a basis for correction of the records of the individual concerned.



      _______ _   X_______   ___
               CHAIRPERSON
      
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.



ABCMR Record of Proceedings (cont)                                         AR20150005844





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ABCMR Record of Proceedings (cont)                                         AR20150005844



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