BVA9501381 DOCKET NO. 93-18 914 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an increased disability evaluation for psychoneurosis and an anxiety state, with somatic complaints, currently evaluated as 30 percent disabling. 2. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Theresa M. Catino, Associate Counsel INTRODUCTION The veteran served on active duty from May 1940 to March 1945. In the substantive appeal, which was received at the regional office (RO) in November 1992, the veteran appeared to raise the issues of entitlement to service connection on a secondary basis for heart disease and for "other physical conditions." These matters are not inextricably intertwined with the current appeal and are referred to the RO for appropriate action. REMAND The most recent VA examination that the veteran underwent for his service-connected psychoneurosis and anxiety state, with somatic complaints was conducted in February 1993. In the report of this examination, the examiner discussed some objective findings regarding the veteran's mental condition. Significantly, however, the examiner did not discuss the extent of the veteran's social and industrial impairment resulting from his service-connected psychoneurotic disorder. In particular, the examiner did not provide a finding of the veteran's functional impairment under the Global Assessment of Functioning Scale. The veteran is evaluated for his serviced-connected psychoneurosis and anxiety state, with somatic complaints under Diagnostic Code 9400. A reading of this Code also indicates that the veteran's psychoneurotic disorder must be evaluated based on the extent of social and industrial impairment resulting from such disorder. In light of these regulations, the Board concludes that the veteran should be accorded an additional VA psychiatric examination to determine the extent of his social and industrial impairment resulting from his service-connected psychoneurotic disorder. In addition, the Board notes that the most recent record of outpatient treatment that the veteran received for his psychoneurotic disorder is dated in April 1992. The United States Court of Veterans Appeals (Court) has held that there is a continuing obligation on the VA to assist the veteran in developing the facts of his claim throughout the entire administrative adjudication. This obligation includes the duty to obtain records regarding the veteran's medical history. Murincsak v. Derwinski, 2 Vet.App. 363, 373 (1992). VA has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1991). This duty to assist includes the duty to develop facts when the record before the Board is clearly inadequate. EF v. Derwinski, 1 Vet.App. 324 (1991); Littke v. Derwinski, 1 Vet.App. 90 (1990). The development of facts includes a "thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one." Green v. Derwinski, 1 Vet.App. 121, 124 (1991). The Board concludes that further assistance to the veteran is required. Accordingly, the case is REMANDED to the RO for the following: 1. The veteran should be contacted and requested to furnish a complete list of all medical personnel and facilities from which he has received treatment for his service-connected psychiatric disorder since 1991. The Board is particularly interested in records of any treatment that the veteran may have received from VA facilities. After obtaining the appropriate releases from the veteran where necessary, the health care providers should be contacted and requested to provide copies of all treatment records in their possession pertaining to the veteran. If these records are unavailable, that fact should be annotated in the claims folder. Any available records should be associated with the claims folder. 2. Following the above, the veteran should be examined by a VA psychiatrist, who has not previously examined him, to determine the nature and extent of his service-connected psychiatric disorder. The report of examination should include a detailed account of all manifestations of psychiatric pathology found to be present. If there are different psychiatric disorders, the psychiatrist should reconcile the diagnoses and should specify which symptoms are associated with and which disorders are part of or caused by the service-connected disorder. If certain symptomatology cannot be disassociated from one disorder or another, it should be specified. The psychiatrist should describe how the symptoms of the service-connected psychiatric disorder affect the veteran's social and industrial capacity. The examiner should be requested to express an opinion as to the extent of industrial impairment which is the result of this disorder. All necessary special studies or tests, including psychological testing, are to be accomplished. The examiner should comment upon the veteran's functional impairment resulting only from his service-connected psychoneurosis and anxiety state, with somatic complaints, by utilizing the Global Assessment of Functioning Scale found in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. It is imperative that the physician explain the significance of the numerical code assigned. The entire claims folder and a copy of this remand must be made available to and reviewed by the examiner prior to the examination. 3. Thereafter, the RO should formally adjudicate the issue of entitlement to an increased rating for the service-connected psychiatric disorder. Following completion of these actions, and, if the decision remains unfavorable, the veteran and his representative should be provided with a supplemental statement of the case and afforded a reasonable period of time in which to respond. Thereafter, the case, in accordance with the current appellate procedures, should be returned to the Board for completion of appellate review. The issue of whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for hypertension is deferred pending the completion of the development of the veteran's increased rating claim. The purpose of this REMAND is to obtain clarifying evidence. No action is required of the veteran until further notice is issued. JOHN E. ORMOND 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 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).