BVA9505584 DOCKET NO. 89-10 600 ) DATE ) RECONSIDERATION ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to a increased rating for post traumatic stress disorder, currently rated as 50 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. R. Olson, Counsel INTRODUCTION The veteran's active military service extended from September 1943 to September 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 1988 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona, which continued a 50 percent rating for post traumatic stress disorder (PTSD) that had been in effect since June 1983. The Board of Veterans' Appeals entered a decision in this case on December 27, 1989. Subsequently, a Motion for the Reconsideration of that decision was filed with the Board. Reconsideration of the decision has been ordered by the authority granted to the Chairman in 38 U.S.C.A. § 7103 (West 1991) and the case is now before an expanded Reconsideration Section of the Board. This remand is in the nature of a preliminary order and is not the Board's final decision on the veteran's claim. When the Reconsideration Section renders its final decision, it will replace the decision of December 27, 1989 and be the final decision of the Board. REMAND VA has a duty to assist the veteran in the development of his claim. 38 U.S.C.A. § 5107(a) (West 1991). Since the Board's December 1989 decision, the United States Court of Veterans Appeals has rendered several decisions dealing with the duty to assist in various situations. Some of these situations are presented in this case. Therefore, the Board is deferring final action so that VA can assist the veteran in the further development of his claim. The veteran's complete medical record should be available for medical examiners and adjudicators. 38 C.F.R. §§ 4.1, 4.2 (1994). In attachments to a VA Form 9, dated in March 1993, the veteran stated that all of his treatment has been with VA and specifically mentioned the Daytona Beach clinic. However, the record shows that the veteran is receiving benefits from the Social Security Administration and that the claim originated while he was living in Arizona. These factors raise a possibility that there are other relevant medical records available. This should be clarified and, if there are other records, they should be obtained. See Ferraro v. Derwinski, 1 Vet.App. 326, 334 (1991). The veteran reports that on the recent VA examination, the physician said he had not had time to review the file. The duty to assist includes conducting a through examination which takes into account the records of prior examination and treatment. See Fanning v. Brown, 4 Vet.App. 225, 230 (1993). The veteran should be accorded another VA examination, in which the examiner has the veteran's medical records and has reviewed them. On the November 1992 VA psychiatric examination, the physician recommended psychological testing. Special tests recommended by VA examiners should be done. See Hyder v. Derwinski, 1 Vet.App. 221 (1991). To ensure that VA has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following development: 1. The RO should obtain the names and addresses of all medical care providers who treated or examined the veteran for his psychiatric disorder since May 1986. After securing the necessary releases, the RO should obtain these records. 2. The RO should obtain from the Social Security Administration the records pertinent to the appellant's claim for Social Security benefits as well as any medical records relied upon concerning that claim. 3. A complete copy of the veteran's VA medical records should be obtained and associated with the claims folder. Records from the VA outpatient clinic at Daytona Beach are particularly desirable. 4. The veteran should be afforded a VA psychological examination to include a complete battery of psychological tests appropriate for PTSD, such as the Minnesota Multiphasic Personality Inventory (MMPI) and the Mississippi Scale for Combat-Related Post- Traumatic Stress Disorder. A copy of this remand and the claims folder should be made available to the examiner for review before the examination. 5. Following the above, the veteran should be examined by a panel of two VA psychiatrists who have not previously examined him. Each psychiatrist should conduct a separate examination with consideration of the criteria for post- traumatic stress disorder. The examination report should include a detailed account of all pathology found to be present. If there are different psychiatric disorders than post-traumatic stress disorder, the board should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). If certain symptomatology cannot be disassociated from one disorder or another, it should be specified. The psychiatrists should describe how the symptoms of post-traumatic stress disorder affect the veteran's social and industrial capacity. The report of examination should include a complete rationale for all opinions expressed. All necessary special studies or tests including any additional psychological testing and evaluation should be done. The psychiatrists should review the results of such tests before completing their reports. The examiners should assign a numerical code under the Global Assessment of Functioning Scale (GAF). It is imperative that the physicians include a definition of the numerical code assigned. Thurber v. Brown, 5 Vet.App. 119 (1993). The diagnosis should be in accordance with the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (3d ed. rev., 1987). The entire claims folder and a copy of this remand must be made available to and reviewed by the examiners prior to the examination. 6. The RO should review the examination report and determine if it is adequate for rating purposes and in compliance with this Remand. If not, the report should be returned for corrective action. Following completion of these actions the RO should review the veteran's claim. If the decision remains unfavorable, the veteran and representative should be provided with a supplemental statement of the case and afforded a reasonable period of time in which to respond. Thereafter, in accordance with the current appellate procedures, the case should be returned to the Board for completion of appellate review. The Board intimates no opinion as to the ultimate outcome of this case. No action is required of the veteran until further notice is issued. JAN DONSBACH VICKY L. JORDAN Member, Board of Veterans' Appeals Member, Board of Veterans' Appeals JOAQUIN AGUAYO-PERELES Member, Board of Veterans' Appeals GEORGE R. SENYK NANCY I. PHILLIPS Member, Board of Veterans' Appeals Member, Board of Veterans' Appeals SAMUEL W. WARNER Member, Board of Veterans' Appeals 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 remand 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).