BVA9508078 DOCKET NO. 93-13 360 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Susan S. Toth, Associate Counsel INTRODUCTION The veteran had active service from July 1969 to February 1971. This matter arises from a September 1992 rating decision, whereby the Regional Office (RO) denied the veteran's claim for an increased evaluation for post-traumatic stress disorder (PTSD). REMAND During the hearing conducted at the RO in March 1993, the veteran stated that he received continuing counseling for PTSD from Keith Maneese at North Central Psychological Services. Prior to a determination on appeal, recent counseling records should be obtained from that facility. In this regard, the 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. § 3.303(a) (1994). The United States Court of Veterans Appeals (Court) has held that the duty to assist the veteran includes obtaining available medical records that are relevant to the appeal. Littke v. Derwinski, 1 Vet.App. 90 (1990). The duty to assist also includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran which takes into account the records of prior medical treatment. Green v. Derwinski, 1 Vet.App. 121, 124 (1991). This is to ensure that the evaluation of the disability is a fully informed one. Since recent treatment records are to be acquired, the veteran should be provided with a contemporaneous VA examination in psychiatry by an examiner who has the benefit of reviewing all pertinent psychiatric treatment records. Finally, the veteran appears to have applied for vocational rehabilitation benefits in l992. The rehabilitation and education folder should be obtained to see if it contains information pertinent to the veteran's current claim. Under the circumstances of this case, the Board finds that additional assistance is required. Accordingly, the case is REMANDED to the RO for the following: 1. Obtain the veteran's rehabilitation and education folder and any related subfolders. 2. Request the veteran to furnish the names and addresses of all medical care providers who treated him for PTSD since 1992. Thereafter, the RO should acquire copies of all available medical records to include those from North Central Psychological Services dated from September 1991 to the present. Once obtained, all records must be associated with the claims folder. 3. Schedule the veteran for a comprehensive VA psychiatric examination. 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's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERs (3rd ed. rev., 1987), and explain what the assigned score represents. In particular, the Board is required to determine the effect of the veteran's psychiatric disorder on his ability to obtain and retain employment and get along with others in an employment situation. A complete rationale for any opinion expressed must be provided. 4. Following completion of the foregoing, 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. 5. After the development requested above has been completed to the extent possible, again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the appellant and representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board in accordance with current appellate procedures. The appellant need take no action until he is further informed. The purpose of this REMAND is to obtain additional information, and no inference should be drawn regarding the final outcome of this claim as a result of this action. I. S. SHERMAN 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).