BVA9505089 DOCKET NO. 93-15 596 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to an increased rating for paranoid type schizophrenia, currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Jeffrey A. Pisaro, Counsel INTRODUCTION The veteran had active service from February 1974 to August 1983. This appeal arises from a December 1990 rating decision of the Chicago, Illinois, Regional Office (RO). The Board notes that the issue of entitlement to a total rating based on individual unemployability due to service connected disability has been raised; however, as that issue is not inextricably intertwined with the issue currently on appeal, it is referred to the RO for appropriate consideration. REMAND The duty to assist includes affording the veteran a thorough and contemporaneous examination that takes into account the records of prior medical treatment. Green v. Derwinski, 1 Vet.App. 121 (1991). This is to ensure that the evaluation of a disability is a fully informed one. The severity of psychiatric disability is based upon actual symptomatology as it affects social and industrial adaptability. See 38 C.F.R. §§ 4.129, 4.130 (1993). Since the last Department of Veterans Affairs (VA) psychiatric rating examination in October 1992, the veteran was hospitalized for an undetermined length of time in May 1993 due to psychiatric disability; however, the hospital records have not been obtained. Moreover, the October 1992 VA examination report did not include a Global Assessment of Functioning scale code or provide an opinion with respect to the veteran's ability to work. In view of the foregoing, the Board is persuaded that the veteran should be afforded a further VA psychiatric examination in connection with this appeal. VA has a duty to assist the veteran in the development of facts pertaining to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1993). The United States Court of Veterans Appeals (Court) has held that the duty to assist includes obtaining available records which are relevant to the claimant's appeal. The duty to assist is neither optional nor discre- tionary. Littke v. Derwinski, 1 Vet.App. 90 (1990). The veteran has been receiving continuing treatment for his psychosis at the West Side Chicago VA medical center; complete records should be obtained from that facility. Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and obtain the names and addresses of all mental health care providers from whom he has received treatment in recent years. Thereafter, the RO should obtain legible copies of all records which have not already been obtained, to include those from the West Side Chicago VA medical center from May 1992 (inclusive of the May 1993 hospitalization) to the present. Once obtained, all records must be associated with the claims folder. 2. Following completion of the above development, the veteran should be afforded a comprehensive VA examination in psychiatry. This study should be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations. All indicated tests, including appropriate psychological studies with applicable subscales, should be conducted. The claims file must be made available to and reviewed by the examiner prior to the examination. The disability should be evaluated in relation to its history, with emphasis upon the limitation of activity, to include time lost from employment, imposed by the service-connected schizophrenia. The examiner should assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association's Diagnostic and Statistical Manual For Mental Disorders, and explain what the assigned score represents. In addition, the examiner should also discuss the impairment of social and industrial adaptability attributable to the psychosis (as distinct from impairment attributable to other conditions). 3. When the requested development is fully completed, the RO should readjudicate the veteran's claim. The rating decision should reflect consideration of the appli- cability of the provisions of 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.129, and 4.130. Unless the claim is granted to the veteran's satisfaction, he and his representative should be furnished with a supplemental statement of the case. They should then be afforded the applicable time to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. CHARLES E. HOGEBOOM 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).