BVA9508258 DOCKET NO. 93-17 716 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder, currently rated at 50 percent. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. M. Flatley, Counsel REMAND The veteran had active service from September 1968 to September 1972. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 1993 rating decision of the Nashville, Tennessee, Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for post-traumatic stress disorder was initially granted by a June 1992 rating decision and was rated at 30 percent. A 50 percent evaluation was assigned by an August 1992 rating decision. Review of the record indicates that the veteran has submitted a well-grounded claim. 38 U.S.C.A. § 5107(a) (West 1991). The VA therefore has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet.App. 78, 81-82 (1990). In this case, the veteran's most recent VA psychiatric examination was conducted in May 1992. Outpatient records demonstrating pertinent complaints and treatment were submitted subsequent thereto, and, in part, provided the basis for the aforementioned increase in the veteran's disability rating to 50 percent. Additional outpatient reports were received thereafter, however, which reflect that the veteran may be experiencing an increase in psychiatric symptomatology. It appears that the veteran undergoes regular treatment of his service-connected post-traumatic stress disorder. The Board notes that although in his substantive appeal, the veteran reported that he was no longer employed, VA outpatient entries dated in May and August 1994 reflect that the veteran maintains employment. In light of the overall evidence of record, the Board is of the opinion that additional clinical data may prove helpful in the evaluation of the veteran's claim. In order to fully assist the veteran in the development of his case, therefore, and extend to the veteran every equitable consideration, additional development is warranted. As such, this case is REMANDED for the following: 1. After any necessary information and authorization are obtained from the veteran, duplicates of any recent treatment, VA or private, inpatient or outpatient, associated with the veteran's post-traumatic stress disorder, and not previously of record, should be obtained by the RO and incorporated into the claims folder. 2. A VA psychiatric examination should be arranged to determine the extent and severity of the veteran's service-connected post-traumatic stress disorder. The examination should be conducted in accordance with the appropriate provisions of the VA's Physician's Guide for Disability Evaluation Examinations. The examination report should include a detailed description of the veteran's symptoms, clinical findings, and associated functional impairment (as demonstrated socially and industrially); all indicated studies should be done. The examiner should identify the level of functional impairment associated with the veteran's service-connected post-traumatic stress disorder and should discuss any reduction in initiative, reliability, and flexibility levels which is due to post-traumatic stress disorder. In this regard, the terms mild, definite, considerable, severe and total are the preferred descriptive adjectives. A comprehensive report, which includes the examiner's conclusions and the foundation upon which they are based, as well as the history of the veteran's disability, should be provided and associated with the veteran's claims folder. The veteran's claims folder should be made available to the examiner and should be reviewed prior to the examination. 3. The RO should then review the veteran's claim. All pertinent law, regulations, and United States Court of Veterans Appeals (Court) decisions should be considered, including Schafrath v. Derwinski, 1 Vet.App. 589 (1991). If the veteran's claim remains in a denied status, he and his representative should be provided with a supplemental statement of the case, which includes any additional pertinent law and regulations and a full discussion of action taken on the veteran's claim, consistent with the Court's instruction in Gilbert v. Derwinski, 1 Vet.App. 49 (1990). The applicable response time should be allowed. The case should then be returned to the Board, if in order, after compliance with customary appellate procedures. No action is required of the veteran until he is so informed. The Board intimates no opinion as to the ultimate decision warranted in this case, pending completion of the requested development. THOMAS J. DANNAHER 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 action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 133-446, § 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) (1994).