BVA9508106 DOCKET NO. 93-12 095 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently rated 50 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Richard V. Chamberlain, Counsel INTRODUCTION The veteran served on active duty from August 1967 to May 1975. This case comes to the Board of Veterans' Appeals (Board) from a decision by a Department of Veterans Affairs (VA) Regional Office (RO) which denied an increased rating for service-connected PTSD. A December 1991 RO decision assigned a temporary total hospital rating effective from September 4, 1991, followed by a 10 percent rating from October 1, 1991. The veteran filed a timely notice of disagreement with regard to the issue of an increased rating for PTSD; a statement of the case was issued; and the veteran filed a timely substantive appeal on the matter. Subsequent RO decisions extended the temporary total hospital rating to cover the period of September 4, 1991 through June 30, 1992, and assigned a 50 percent rating from July 1, 1992. Since this RO action did not grant complete relief to the veteran, the current issue on appeal remains entitlement to an increased rating for PTSD, now rated 50 percent. See Corchado v. Derwinski, 1 Vet.App. 160 (1991). The Board notes that a July 1992 supplemental statement of the case added an issue of service connection for hypertension and a skin disorder. However, that issue is not before the Board as a related substantive appeal was not filed within 60 days of the veteran and his representative being provided with the supplemental statement of the case which added the issue. 38 U.S.C.A. §§ 7105, 7108 (West 1991); 38 C.F.R. § 20.302(c) (1994); Roy v. Brown, 5 Vet.App. 554 (1993). Likewise, a February 1993 supplemental statement of the case added an issue of entitlement to an effective date earlier than September 4, 1991 for service connection for PTSD (in fact, this is the only issue the RO certified for Board review); but this issue also is not before the Board because a substantive appeal was not submitted within 60 days of the veteran and his representative being provided with the supplemental statement of the case which added the issue. Id. REMAND The veteran's claim is well grounded, meaning not inherently implausible. The VA has a duty to assist him in developing facts pertinent to these claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. §§ 3.103(a), 3.159 (1994). The duty to assist includes obtaining all relevant records and providing an adequate VA examination. Murphy v. Derwinski, 1 Vet.App. 78 (1990); Littke v. Derwinski, 1 Vet.App. 90 (1990). The latest medical records on file are those from a January-June 1992 VA hospitalization, during which the veteran received psychiatric treatment for PTSD. At discharge it was noted he was to receive follow-up outpatient care. The ongoing records of treatment should be obtained. Murincsak v. Derwinski, 2 Vet.App. 363 (1992). His psychiatric symptoms after this hospital stay are not shown and he should undergo a VA psychiatric examination to determine the current severity of PTSD, especially in light of the allegation of worsened disability and the fact that the last relevant medical records on file are about three years old. Caffrey v. Brown, 6 Vet.App. 377 (1994); Weggenmann v. Brown, 5 Vet.App. 281 (1993). In view of the foregoing, the case is REMANDED to the RO for the following actions: 1. The RO should ask the veteran and his representative to identify all sources of hospital or outpatient treatment and/or examination (VA or non-VA) for any psychiatric condition (including PTSD) since June 1992. Exact names and addresses of medical providers and dates of treatment and/or examination should be listed. After obtaining any needed release forms, the RO should directly contact the sources and obtain copies of all records not already on file. 2. After the above records are added to the claims folder, the RO should have the veteran undergo a VA psychiatric examination to determine the severity of his PTSD. The claims folder must be made available to and reviewed by the psychiatrist prior to the examina-tion. All indicated studies should be performed and all clinical findings should be reported in detail. The psychiatrist should delineate which psychiatric symptoms are attributable to each psychiatric disorder found. The examiner should specifically discuss the effects of each psychiatric disability on the veteran's employability, and support all opinions by discussing medical principles as applied to specific medical evidence in the veteran's case. The RO should then review the claim for an increase in the 50 percent rating for PTSD. If the claim is denied, the veteran, and his representative should be provided with a supplemental statement of the case and given an opportunity to respond. Then the case is returned to the Board for further appellate consideration. L. W. TOBIN 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) (1994).