BVA9501944 DOCKET NO. 93-08 745 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to an increased disability rating for post-traumatic stress disorder, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Theresa M. Catino, Associate Counsel INTRODUCTION The veteran served on active military duty from May 1970 to January 1972. REMAND A letter dated in February 1992 from the Department of Veterans Affairs (VA) Post-Traumatic Stress Disorder Clinic in New York, New York indicated that the veteran was receiving treatment at that medical facility. In a substantive appeal received in the same month pursuant to a prior claim, the veteran contended that he continued to receive treatment for his post-traumatic stress disorder at the VA medical facility. Furthermore, at a personal hearing conducted before a hearing officer at the regional office (RO) in June 1992, pursuant to a prior appeal, the veteran testified that he was receiving treatment from Dr. Hanover and Stephen Grossman at the Post-Traumatic Stress Disorder Clinic for the prior six months. According to his testimony, he had been originally receiving treatment for his post-traumatic stress disorder once a week but, at the time of the hearing, was only going for treatment once every two weeks due to the cost of transportation to the medical facility. Hearing transcript at 3, 12. In addition, in the notice of disagreement, which was received at the RO in October 1992 pursuant to the current appeal, the veteran asserted that his post-traumatic stress disorder requires weekly individual sessions with his doctor at the New York VA Post-Traumatic Stress Disorder Clinic. In November 1992, the RO requested the veteran's medical records from the Outpatient Clinic at the VA Medical Center in New York, New York. This search failed to find any records of treatment that the veteran received for his post-traumatic stress disorder. Significantly, however, the RO did not specifically request the veteran's treatment records from the New York VA Post-Traumatic Stress Disorder Clinic and did not ask for records of treatment that the veteran received from Dr. Hanover and Stephen Grossman at this medical facility. Subsequently, in the substantive appeal which was received at the RO in February 1993 pursuant to the present appeal, the veteran continued to assert that he is receiving treatment for his post-traumatic stress disorder. Significantly, a review of the claims folder indicates that the RO did not yet attempt to obtain these records. 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 of Veterans' Appeals (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 post-traumatic stress disorder since April 1991. 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 RO should schedule the veteran for a comprehensive VA psychiatric examination to determine the extent of his service-connected post-traumatic stress disorder. This study must be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations. All indicated tests, including appropriate psychological studies with applicable subscales, must be conducted. The claims file must be made available to and reviewed by the examiner prior to the requested study. The examiner must assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders and explain what the assigned score represents. A complete rationale for any opinion expressed must be provided. 3. Following completion of the foregoing, the RO must review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, including if the requested examination does not include all test reports, special studies, or opinions requested, appropriate corrective action is to be implemented. 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 purpose of this REMAND is to obtain clarifying evidence. No action is required of the veteran until further notice is issued. M. SABULSKY 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).