BVA9504144 DOCKET NO. 93-09 136 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to an increased evaluation for status post patellectomy, chondromalacia, left knee with degenerative joint disease, status post synovectomy and realignment of the extensor mechanisms with tibial tubercle advancement using an iliac crest bone graft, status post infection requiring rectus abdominis muscle transplant and split thickness skin graft, currently evaluated as 30 percent disabling. 2. Entitlement to an increased evaluation for major depression, currently evaluated as 10 percent disabling. 3. Entitlement to an increased evaluation for surgical scar, status post left rectus abdominis muscle transplant to left leg and split thickness skin graft from right thigh to left leg, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from March 1964 to July 1965. This appeal arose from a February 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The RO denied entitlement to an increased evaluation for major depression; extension of a temporary total convalescence evaluation for disability of the left knee beyond December 31, 1991; and a total disability evaluation for compensation on the basis of individual unemployability. In an April 1992 rating decision, the RO granted entitlement to extension of a temporary total convalescence evaluation for left knee disability through March 31, 1992. In a rating decision issued in October 1992, the RO granted entitlement to service connection for anterior nerve and muscle loss with complete foot drop deformity, left foot, and assigned a 40 percent evaluation; granted service connection for a surgical scar, status post left rectus abdominis muscle transplant to left leg and split thickness skin graft from right thigh to left leg, and assigned a 10 percent evaluation; affirmed the prior denials of entitlement to increased evaluations for left knee disability and major depression; and granted entitlement to a total disability evaluation for compensation on the basis of individual unemployability. The case has been forwarded to the Board of Veterans' Appeals (Board) for appellate review. REMAND The representative has expressed concern that the appellant was not properly evaluated as to the nature and extent of her disabilities, particularly her psychiatric disability, as no medical records had been made available for review prior to examination. In this regard, a review of the evidence of record discloses that when the appellant was orthopedically examined by VA in July 1992, the examiner specifically stated that he was relying on her subjectively furnished medical history and was recording it as given by the appellant. There is no indication that he had the claims file available for review prior to or during the examination. The July 1992 VA examination for scars contains no acknowledgment by the VA examiner that the appellant's claims file was available for review prior to or during the examination. The July 1992 VA psychiatric examiner specifically noted that the claims file was not available for review prior to the examination. The VA general medical examiner also specifically noted that no medical records whatsoever were made available for that examination which was also conducted in July 1992. The fact that the July 1992 VA examinations were conducted without access to the appellant's claims file renders the subject examinations inadequate for rating purposes. See, e.g., 38 C.F.R. § 4.1 (1994) ("It is...essential both in the examination and in the evaluation of the disability, that each disability be viewed in relation to its history.") See also Green v. Derwinski, 1 Vet.App. 121, 124 (1991) ("[F]ulfillment of the statutory duty to assist...includes the conduct of 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." (emphasis added)). Accordingly, further development is warranted. Further development is also warranted in light of the veteran’s numerous hospitalizations in recent years. In this respect, the Board observes that while operative summaries are of record for numerous procedures, all of the discharge summary reports for care received at Mission Bay and Mercy Hospitals in 1991 and 1992 are not of record. Hence, further action is desirable. Finally, the Board notes that volume "I" of the veteran’s three volume claims file is in dire need of repair. In order preserve the integrity of the appellant’s record, corrective action must be initiated at once. Therefore, in accordance with the VA's duty to assist the veteran in the development of facts pertinent to her claim under 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994), the Board is deferring adjudication of the issues prepared and certified for appellate review pending a REMAND of the case to the RO for further development as follows: 1. Before conducting any of the development outlined below, the RO shall repair volume I of the veteran’s claims folder by replacing the current volume with a file where all of the veteran’s records have been secured into the volume with "Acco" or like type fasteners. 2. The RO should contact the appellant and request that she identify each and every health care provider, VA or private, from whom she has received either inpatient or outpatient care for any service connected disorder since 1991. Upon receipt of the veteran’s response the RO should contact all identified providers, and request that they provide photocopies of all identified records. In particular the RO should secure any and all discharge summaries pertaining to all pertinent periods of inpatient care at either Mission Bay Hospital, 3030 Bunker Hill Street, San Diego, California 92109; or Mercy Hospital and Medical Center, San Diego, California. 3. Following the completion of the foregoing, the RO should arrange for VA orthopedic and surgical examinations of the veteran to determine the nature, extent, and degree of industrial impairment caused by each of her service connected orthopedic and postoperative disorders. These examinations must be conducted in accordance with the VA Physician’s Guide for Disability Evaluation Examinations. All indicated studies are to be conducted. The claims file must be made available to and reviewed by the examiners prior to the examinations. 4. The RO should also schedule the veteran for an examination by a VA psychiatrist to determine the extent of severity of her major depression. All indicated studies are to be conducted. The examiner should assign a numerical score based on the Global Assessment of Functioning Scale provided by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, (3rd. ed. 1987) (DSM-III-R), and explain what the assigned score represents. The claims file must be made available to and reviewed by the examiner prior to the examination. 5. Thereafter, the RO should review all examination reports to ensure that they are in complete compliance with the instructions contained in this REMAND. If the examination reports are not in complete compliance, appropriate corrective action is to be implemented at once. 6. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issues of entitlement to increased evaluations for the disabilities at issue. If the benefits requested on appeal are not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until she is notified by the RO. DEREK R. BROWN 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).