BVA9503819 DOCKET NO. 93-09 435 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The veteran and Ms. [redacted] ATTORNEY FOR THE BOARD Daniel J. McTavish, Associate Counsel INTRODUCTION The veteran served on active duty from October 1968 to January 1972. This matter came before the Board of Veterans' Appeals (Board) on appeal of an August 1991 rating decision by the St. Petersburg, Florida Regional Office (RO) of the Department of Veterans Affairs (VA), which, among other actions, denied the veteran's claim for an increased rating for PTSD. That rating action did assign a temporary 100 percent rating from May 28, 1991 through July 31, 1991, under 38 C.F.R. § 4.29, based upon hospitalization for PTSD, with resumption of the prehospitalization rate of 30 percent, effective August 1, 1991. REMAND On May 28, 1991, the veteran was admitted at the VA Hospital in Bay Pines, Florida, for treatment of his PTSD. He was discharged on July 19, 1991, with instructions for followup care at the Bay Pines, Mental Health Clinic, and the St. Petersburg, Vet Center. There are no records of followup treatment in the claims file. The veteran and his niece appeared and offered testimony at a hearing before a hearing officer at the RO in April 1992. The veteran reported that he attended group meetings once a week at the Tampa and St. Petersburg Vet Centers. In June 1992, a letter was received by the RO from Stephen Crane, a counselor at the Vet Center in Tampa, Florida. Mr. Crane stated that the veteran had been involved in group counseling at this facility since March 1992. Records related to his group therapy at this Vet Center or the St. Petersburg Vet Center are not in the claims file. Although the veteran was evaluated by the VA during his period of inpatient treatment beginning in May 1991, he has not been afforded a comprehensive VA psychiatric examination since August 1989. In view of the passage of time since the veteran was last afforded a VA compensation examination and since it appears there may be additional relevant treatment records which are not in the claims file, the Board finds that the veteran is entitled to further assistance from the VA. The United States Court of Veterans Appeals (Court) has held that the duty to assist the veteran in obtaining and developing available facts and evidence to support his claim includes obtaining evidence from any source, and obtaining adequate VA examinations. Littke v. Derwinski, 1 Vet.App. 90 (1990). This duty also includes obtaining available evidence to support the claim. Murphy v. Derwinski, 1 Vet.App. 78 (1990). In view of the foregoing, the Board finds that further development is in order to assist the veteran in the development of his claim. Therefore, the case is REMANDED to the RO for the following action: 1. All up-to-date VA and any private clinical records for the veteran should be obtained and incorporated into the claims file. In connection therewith, the RO should contact the veteran, through his representative, and ask him to identify all current sources of medical treatment for his service-connected PTSD. All records should be obtained in compliance with appropriate procedure. Specifically, the RO should attempt to obtain any treatment records for the veteran at the Bay Pines Mental Health Clinic and the Vet Centers in Tampa and St. Petersburg, Florida, from July 1991 to the present, 2. Thereafter, the RO should schedule the veteran for a comprehensive VA neuropsychiatric examination in order to determine the severity of his PTSD. This examination 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 examiner should assign a Global Assessment of Functioning score consistent with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III- R), and explain what the assigned score represents. A complete rationale for any opinion expressed must be provided. In accordance with recent Court decisions, the claims folder should be made available to the examiner for review prior to the requested examination. 3. Following completion of the foregoing, the case should be reviewed by the RO. If the decision remains adverse to the veteran, the RO should issue a supplemental statement of the case summarizing the evidence, law and regulations, and explaining how the law and regulations apply to the evidence. The RO should afford the veteran and his representative 60 days to respond to the supplemental statement of the case before the matter is returned to the Board for final adjudication, if otherwise in order. 38 C.F.R. 20.302(c) (1993). The purpose of this REMAND is to procure clarifying data. No action is required of the veteran until further notice. D. C. SPICKLER 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).