BVA9505310 DOCKET NO. 93-14 748 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Arizona Veterans Service Commission WITNESSES AT HEARING ON APPEAL Appellant and Robert Baker, Ph.D. ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel REMAND The veteran had active service from May 1967 to December 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona, which confirmed and continued a 10 percent rating for the veteran's post-traumatic stress disorder. During the course of the appeal additional evidence was developed, and the rating was increased to 30 percent, effective August 22, 1991. The veteran has continued his appeal for an even higher schedular rating. In his substantive appeal dated in November 1992, the veteran indicated that one of his two treating physicians had left the area and the other would be leaving within the week. Over three years have elapsed since that time and there is no indication what the veteran has done for treatment since 1992. He was last accorded a psychiatric examination by VA in October 1991. VA has a duty to assist the veteran in the development of facts pertinent to his claim under 38 C.F.R. § 3.103(a)(1994). The United States Court of Veterans Appeals (Court) has held that fulfillment of the VA's duty to assist the veteran includes providing him with a thorough and contemporaneous medical examination. Littke v. Derwinski, 1 Vet.App. 90, 92 (1990). The record reveals that subsequent to the October 1991 examination, a March 1992 statement from James G. Hill, M.D., one of the veteran's principal treating physicians, stated that the veteran had deteriorated recently and was not functioning well, despite aggressive psychiatric and psychological therapy. Robert Baker, Ph.D., testified at the RO hearing in March 1992 that if the veteran were off his medication, he would be a danger to others and possibly to himself. In view of the foregoing, and the Board's duty to assist the veteran in the development of facts pertinent to his claims, as mandated by 38 U.S.C.A. § 5107(a) (West 1991). The case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and request that he provide the names and addresses of all health care providers who have treated him for psychiatric disability since 1992 and specify the approximate dates of treatment, if possible. Then, after any necessary authorization is obtained from the veteran, the RO should obtain copies of any treatment records identified by the veteran. 2. The veteran should be afforded a VA psychiatric examination to determine the severity of the post-traumatic stress disorder. This examination should be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations. Any psychological studies needed for diagnostic purposes or which would be helpful in evaluating the severity of psychiatric symptomatology should be accomplished. The claims folder should be made available to the examiner prior to the examination and the examiner should review that file prior to the examination. The examiner should elicit from the veteran information regarding his employment status, particularly time lost from work. The examiner should provide a numerical and narrative assessment of the veteran's level of functioning as measured by the Global Assessment of Functioning scale code. Additionally, the examiner should specifically state whether or not the post- traumatic stress disorder results in reduction in initiative, flexibility, efficiency, and reliability levels, and if so, how this relates to the veteran's industrial impairment. 3. After the above actions have been completed, the RO should readjudicate the claim for an increased rating for post- traumatic stress disorder. The rating should reflect consideration of the provisions of 38 C.F.R. § 3.321(b)(1). If the determination remains adverse to the veteran, the RO should issue a supplemental statement of the case which includes a summary of additional evidence, any additional applicable laws and regulations, and the reasons for the decision. The vet- eran and his representative should be afforded the applicable time to respond. The case should then be returned to the Board for further consideration, if otherwise in order. By this REMAND, the Board intimates no opinion, either factual or legal, as to the ultimate conclusion warranted in this case. No action is required of the veteran until he is notified by the RO. 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) (1994).