BVA9500397 DOCKET NO. 93-09 109 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to an increased evaluation for anxiety reaction, currently rated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Auer, Counsel REMAND The veteran served on active duty from June 1947 to July 1956. This appeal arises from an October 1992 rating decision of the Department of Veterans Affairs (VA), Montgomery, Alabama, Regional Office (RO). In that decision, entitlement to an increased evaluation for anxiety reaction was denied. During the course of this appeal, the veteran and his representative have argued that the veteran is unemployable by reason of his service-connected anxiety reaction. This issue has not been addressed by the RO. A review of the record in this case shows that the veteran had been receiving treatment for his service-connected anxiety reaction from the VA on a regular basis. The file does not contain evidence of VA outpatient treatment. The VA has a duty to assist the veteran in the development of facts pertinent to his claim under 38 C.F.R. § 3.103(a) (1993). The United States Court of Veterans Appeals (Court) has held that fulfillment of the VA's duty to assist the veteran includes the procurement and consideration of any relevant medical records. Ferraro v. Derwinski, 1 Vet.App. 326, 334 (1991). The VA 's duty to assist the veteran in the development of facts pertinent to his claim includes providing a thorough and contemporaneous medical examination, which takes into account prior medical evaluations and treatment. Weggenmann v. Brown, 5 Vet.App. 281, 284 (1993). The VA Physician's Guide for Disability Evaluation Examinations (1985) provides some guidance for defining an adequate VA psychiatric evaluation. Chapter 14, Section 1 provides an outline of the information required for a disability evaluation of a psychiatric disorder. A report of evaluation should include: complaints in the veteran's own words, behavioral information, a detailed military history, a description of symptoms (subjective and objective), a vocational history as it relates to the veteran's adjustment to work, a definitive diagnosis based on whole history and current examination, an opinion as to mental competency, a prognostic opinion of any future increase in disability, and data concerning social integration. A more thorough description of the information required is set forth is Chapter 14, pages 14-1 through 14-6 of the Physician's Guide for Disability Evaluation Examinations. The Board finds that further development is warranted before a final decision in this appeal. Accordingly, the claim is REMANDED for the following actions: 1. The RO should contact the veteran and ask him to furnish the names and addresses of all medical personnel and facilities from whom he has received treatment for the disability at issue since September 1987. After obtaining the necessary authorization from the veteran, the RO should obtain available records from the named sources. 2. The RO should obtain any available treatment records from the VA hospitals or medical centers where the veteran has received treatment since October 1992. 3. The veteran should undergo a VA social and industrial survey to ascertain the manner and extent to which the service-connected disorder impairs his ability to work and relate to other people. Comprehensive information should be obtained and reported in accordance with Paragraph 1.14 of the VA Physician's Guide for Disability Evaluation Examinations. Complete information concerning the veteran's work history and the reasons for his discontinuation of work should be obtained. 4. The veteran should then be scheduled for a VA psychiatric examination to determine the nature and extent of all current psychiatric pathology. The examination should be conducted in accordance with the requirements of the VA Physician's Guide for Disability Evaluation Examinations, specifically Chapter 14. All necessary psychological testing should be conducted. The examiner should express an opinion as to the veteran's level of functioning as measured by the Global Assessment of Functioning Scale (GAF Scale) as stated in the Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (3rd ed. revised l987) (DSM-III- R), and the degree of impairment of the veteran to perform substantially gainful employment due to anxiety reaction. It is essential that the claims folder should be provided to the examiner for review in connection with the examination. 5. After the above actions have been completed, the case should again be reviewed by the RO, to include the adjudication of the issue of entitlement to a total rating under 38 C.F.R. § 4.16(a) (b) (1993), if in order, as well as all applicable legal criteria. The RO should then review the veteran's claim in light of all the evidence and applicable legal criteria. If his claim remains denied, the veteran and his representative should be provided with a supplemental statement of the case that includes any additional pertinent law and regulations and a full discussion of the evidence in his case. The appropriate response time should be allowed. The case should then be returned to the Board, if in order, after compliance with all regulatory appellate procedures. No action is required of the veteran until he is so informed. The Board intimates no opinion as to the ultimate decision warranted in this case pending completion of the requested development. ALBERT D. TUTERA Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).