BVA9507328 DOCKET NO. 91-51 416 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES Entitlement to service connection for the residuals of injuries to the right shoulder, hips, and neck. Entitlement to service connection for the residuals of injuries to the knees. Entitlement to service connection for ulcers. Entitlement to service connection for tinnitus. Entitlement to service connection for migraine headaches. Entitlement to service connection for amputations of the fingers and legs. Whether new and material evidence has been submitted to reopen a claim of service connection for a back disability. Entitlement to an increased evaluation for post-traumatic stress disorder, currently rated 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Hilary L. Goodman, Counsel REMAND The veteran had active service from June 1966 to July 1969. This appeal arises from a May 1990 rating decision which granted service connection for post-traumatic stress disorder and assigned a 10 percent disability evaluation. This appeal also arises from an April 1991 rating decision which denied service connection for the residuals of injuries to the right shoulder, hips, and neck, the residuals of injuries to the knees, ulcers, tinnitus, migraine headaches and amputations of the fingers and legs and denied the veteran's request to reopen his claim for service connection for a back disability. In the report of a Department of Veterans Affairs (VA) psychiatric examination conducted in December 1989 it was indicated that the veteran's questionnaire was reviewed but that no other medical record was available to be reviewed. In the report of a VA psychiatric examination conducted in May 1992, it was indicated that neither the veteran's claims file nor clinical records were available. The Court of Veterans Appeals (Court), in Green v. Derwinski, 1 Vet.App. 121, 124 (1991) stated that the "fulfillment 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." Neither examiner provided a Global Assessment of Functioning (GAF) Score or otherwise indicated the degree to which the veteran's psychiatric disorder results in reduction in initiative, flexibility, efficiency and reliability levels. In short the reported findings cannot be related to social and industrial adaptability. The Board of Veterans' Appeals (Board) also notes that a social and industrial survey has not been undertaken in order to determine the veteran's current social and industrial adaptability. The Court, in Massey v. Brown, 7 Vet App. 204 (1994), noted that the findings relied upon by the Board, findings apparently made on VA psychiatric examinations, did not relate to the rating criteria for the psychiatric disability. The examinations were considered inadequate as a result. In view of the foregoing, the Board finds that the veteran's claims for service connection must be deferred and his claim for an increased evaluation for post-traumatic stress disorder REMANDED to the originating agency for the following action: 1. The originating agency should request the veteran to identify all sources of psychiatric treatment and to furnish signed authorizations for release to the VA of his private medical records. The originating agency should obtain copies of medical records (not already in the claims file) from all sources identified by the veteran. All records obtained should be associated with the veteran's claims file. 2. A VA social and industrial survey should be conducted in order to clarify the veteran's medical, social, educational, and employment history since 1989. The social worker should elicit and set forth pertinent facts regarding the veteran's medical history, education, employment history, social adjustment, and current behavior and health. The social worker should obtain information regarding time lost from work by the veteran due to his post-traumatic stress disorder and offer an assessment of the veteran's current functioning. The claims file must be made available to the social worker in conjunction with the survey. 3. Following completion of the above development, the veteran should be scheduled for a VA psychiatric examination to determine the severity of the service- connected post-traumatic stress disorder. The examination should be performed in accordance with the VA Physician's Guide for Disability Evaluation Examinations. All indicated tests, including appropriate psychological studies, should be conducted. The claims file must be made available to and reviewed by the examiner prior to the evaluation. Based upon a review of the record and the examination, the physician must assign a GAF Score consistent with the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, and explain what the assigned score represents. A complete rationale for any opinion expressed must be provided. 4. When the above development has been completed the originating agency should review the veteran's claim. The rating should reflect consideration of the provisions of 38 C.F.R. § 3.321(b)(1). If the determination made remains unfavorable to the veteran, a supplemental statement of the case which provides a summary of the evidence received since the February 1994 supplemental statement of the case should be issued to the veteran and his representative. They should be given the appropriate period of time in which to respond. Thereafter, the case should be returned to the Board for further consideration, if in order. No action is required by the veteran until he receives further notice. The purpose of this REMAND is to obtain clarifying medical information and to afford the veteran due process. ROBERT D. PHILIPP 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).