BVA9505090 DOCKET NO. 93-15 657 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUE Entitlement to an increased rating for post traumatic stress disorder (PTSD), currently evaluated as 70 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Jeffrey A. Pisaro, Counsel REMAND The veteran had active service from August 1967 to February 1971. This appeal arises from a December 1990 rating decision of the Boston, Massachusetts, Regional Office (RO), which denied a rating in excess of 50 percent for PTSD. Following additional development, a hearing officer at the RO determined in August 1992 that a 70 percent rating for PTSD was warranted. In a September 1992 rating decision, the RO increased the rating for PTSD to 70 percent effective from November 7, 1990. The duty to assist includes conducting a thorough and contemporaneous examination of the veteran that takes into account the records of prior medical treatment. Green v. Derwinski, 1 Vet.App. 121 (1991). This is to ensure that the evaluation of a disability is a fully informed one. The severity of psychiatric disability is based upon actual symptomatology as it affects social and industrial adaptability. See 38 C.F.R. §§ 4.129, 4.130 (1993). With respect to the May 1992 VA psychiatric examination report, the Board notes that the examiner did not provide a Global Assessment of Functioning scale code or otherwise indicate the degree to which the psychiatric disorder results in reduction in initiative, flexibility, efficiency and reliability levels. Of record is a May 1991 Social Security Administration (SSA) disability determination and a July 1991 award letter which reflect that the veteran was awarded SSA disability benefits; the disability determination lists low back pain as the primary diagnosis and PTSD and alcohol abuse as secondary diagnoses. It is not clear whether or not all medial records considered by the SSA have been associated with the records assembled for appellate review. VA has a duty to assist the veteran in the development of facts pertaining to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1993). The United States Court of Veterans Appeals (Court) has held that the duty to assist includes obtaining available records which are relevant to the claimant's appeal. The duty to assist is neither optional nor discretionary. Littke v. Derwinski, 1 Vet.App. 90 (1990). The veteran has been receiving ongoing treatment at the Boston VA medical center; complete records should be obtained from that facility. Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should request the veteran to identify all mental health care providers from whom he has received treatment in recent years. Thereafter, the RO should obtain legible copies of all records which have not already been obtained, to include those from the Boston VA medical center and the Boston Veterans Center. Once obtained, all records must be associated with the claims folder. 2. The RO should contact the SSA and obtain legible copies of the medical records upon which that decision was based. 3. The RO should arrange for the veteran to be scheduled for a comprehensive VA psychiatric examination. The examination should be conducted in accordance with the VA Physician's Guide for Disability Evalu- ation Examinations. The claims file must be made available to and reviewed by the examiner prior to the examination. The examiner should elicit from the veteran details concerning his current PTSD symptoms and his account of how these symptoms affect his activities, including his employment opportunities. The examiner should offer an opinion as to the relationship, if any, between the veteran's PTSD symptoms and alcohol abuse. Any psychological testing deemed necessary to make a complete diagnostic evaluation and to differentiate symptoms attributable to PTSD from those due to other conditions should be accomplished. If needed, the psychiatrist should utilize Social Work Service to obtain data to clarify the sequence of events which may have affected the veteran's life and to assist the psychiatrist in evaluating the degree of social, psychological, and industrial impairment due to PTSD. The examiner should assign a Global Assessment of Functioning Scale code and explain what the assigned score represents. In addition, the examiner should discuss the impairment of the veteran's ability to establish and maintain relationships as well as the reduction in initiative, efficiency and reliability levels which may be attributable to the PTSD (as distinct from impairment attributable to other conditions). 4. Following completion of the foregoing, the RO must review the claims folder and ensure that the foregoing development has been completed in full. If any development is incomplete, appropriate corrective action should be implemented. When the requested development is fully completed, the RO should readjudicate the veteran's claim. The rating decision should reflect consideration of the applicability of the provisions of 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.16(c), 4.129, and 4.130. If the claim is not granted to the veteran's satisfaction, he and his representative should be furnished with a supplemental statement of the case. They should then be afforded the applicable time to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. GARY L. GICK 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 deter- mination. 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 action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and 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).