BVA9506301 DOCKET NO. 89-26 731 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Washington, DC THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to an increased rating for residuals of a shell fragment wound of the right leg with retained foreign bodies and a draining ulcer, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Brian J. Milmoe, Counsel REMAND The veteran served on active duty from June 1967 to December 1969. This case was most recently before the Board of Veterans Appeals (BVA or the Board) in January 1994, when it was remanded to the Department of Veterans Affairs (VA) Regional Office (VA) in Washington, DC, for the completion of certain development actions. Such actions were prompted by entry of a memorandum decision by the United States Court of Veterans Appeals, hereinafter the Court, which in pertinent part vacated that portion of the BVA's decision of November 1990, denying the veteran's entitlement to service connection for PTSD and an increased rating for a shell fragment wound to the right leg. [citation redacted]. The Court's action was, in part, based upon certain deficiencies cited by the Secretary of Veterans Affairs in his motion for remand; specifically, the failure of VA to afford the veteran a period of observation and evaluation for PTSD, as had been recommended by an examining VA physician, and uncertainties as to the rating of the veteran's service-connected residuals of a shell fragment wound involving the right leg in light of the unavailability of all service medical records and questions as to whether all pertinent regulatory criteria were considered. Upon return of the case to BVA, it is apparent that little action has been taken by RO personnel to obtain the data sought by BVA in its January 1994 remand action. It is evident that a records request was made of the VA Medical Center in Washington, DC, in August 1994, to which there was no reply, and that the veteran was contacted in writing, albeit an incorrect address, in the same month for the purpose of obtaining PTSD-related information from the veteran. Three days later, he was contacted at the address he had provided to VA in January 1994 for the purposes of advising him of a possible delay in obtaining service department records and requesting that he submit any copies of such records held in his possession. The record otherwise demonstrates no recent attempt by the RO to secure service medical and personnel records. Likewise, no attempt is shown to have been made to secure private medical records specifically referenced by the veteran or to conduct a social and industrial survey and the period of observation and evaluation previously recommended by an examining VA psychiatrist in 1988. As noted in the BVA's prior remand, the veteran has furnished an account of inservice medical treatment for a shell fragment wound of the right leg at several medical facilities of the service department and he has provided VA with records held by him regarding hospital care received in August and September 1968 at the 95th Evacuation Hospital and the United States Army Hospital in the Ryukyu Islands. Those reports are, however, incomplete and for two periods of hospitalization, such reports include only the cover sheet of the clinical record. Also, the veteran has specifically outlined his receipt of mental health care at VA and non-VA facilities between 1977 and 1987, records of which are not now contained within the claims folder. In order to secure additional evidentiary development of this matter, and in light of the veteran's representative's request for additional action, we again REMAND this case to the RO for the completion of the following actions: 1. Through contact with the National Personnel Records Center and direct contact with the applicable service department and their facilities, the RO should obtain a complete set of all service medical and personnel records for the veteran. In addition, a copy of his Department of Defense Form 214 should also be secured. Special efforts should be made to obtain medical records compiled in service with respect to treatment administered for a shell fragment wound of the right leg sustained in March 1968, including medical treatment reportedly received at the 8th Support Group Hospital in Chu Lai, 95th Evacuation Hospital, Naha Memorial Hospital in Okinawa, and the United States Army Hospital in the Ryukyu Islands. 2. The RO should secure all medical records concerning hospital and outpatient treatment obtained by the veteran during post service years for his claimed PTSD and shell fragment wound of the right leg, including all records involving his referral to the Crisis Intervention Clinic of a VA facility in December 1970, in addition to mental health care sought in 1981 and 1987. In addition, upon obtaining authorization from the veteran, the RO should obtain medical records from the Woodburn Mental Health Center in Fairfax County, Virginia, (1977-79), Springfield Community Mental Health Clinic in Virginia (1978), and Fairfax Hospital in Falls Church, Virginia, (1981 suicide attempt), and incorporate same into the veteran's claims folder. 3. The RO should undertake all appropriate action as outlined in the VA's Veterans Benefits Administration Manual, M21-1, paragraph 7.46 (formerly 50.45(e)), in an effort to obtain supportive evidence of any stressful incidents to which the veteran reportedly was exposed while in military service. This development should include, in part, preparation of a detailed account of any claimed stressful events in service, and submission of all appropriate materials to the United States Army and Joint Services Environmental Support Group in an effort to verify those incidents. 4. After the foregoing actions are fully accomplished and the requested information is added to the file, the veteran should be afforded a social and industrial survey by a VA social worker and such evaluation should be conducted at the veteran's residence in accordance with the provisions of Section 1.14 of the Physician's Guide for Disability Evaluation Examinations. Prior to any direct contact with the veteran, the claims folder should be made available to the examiner for use in the study of this case. In addition, the VA social worker should attempt to interview relatives and neighbors of the veteran in an effort to obtain data with respect to the veteran's daily activities, educational and vocational pursuits, current symptoms, and level of functioning. Also, a complete employment history should be compiled and the examiner should conduct interviews with the veteran's most recent employers in order to determine what job-related difficulties, if any, were encountered by the veteran. Once such data are obtained, a written report should be compiled for inclusion in the veteran's claims folder. 5. Thereafter, the veteran should be afforded a period of observation and evaluation at a VA facility in order to assist in determining whether the veteran suffers from PTSD related to his military service, in addition, to obtaining clarifying data which will assist BVA in rating the veteran's service-connected residuals of a shell fragment wound of the right leg. Complete psychological testing, to include all PTSD scales, should be undertaken prior to an examination by a board of two VA psychiatrists to be conducted in accordance with Chapters 14 and 20 of the VA's Physician's Guide for Disability Evaluation Examinations. Each VA psychiatrist should be asked to offer his/her professional opinion as to whether the diagnostic criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) for entry of a diagnosis of PTSD have been met. Also, during the course of the period of observation and evaluation, the service-connected residuals of a shell fragment wound of the veteran's right leg, with retained foreign bodies and a draining ulcer, should be fully evaluated by a VA surgeon, orthopedist, and neurologist. Any and all indicated tests with respect to the veteran's right leg should be undertaken. The claims folder should be made available to all examiners prior to any evaluation of the veteran for use in the study of this case. Upon completion of a review of the entirety of the claims folder, the RO should then readjudicate the issues of the veteran's entitlement to service connection for PTSD and an increased rating for a shell fragment wound of the right leg. As to the claim for increase, the entire clinical history of the disorder in question should be considered and consideration should also be extended to all pertinent statutory and regulatory authority, to include 38 C.F.R. §§ 4.55, 4.56 (1994). If the benefits sought on appeal are not granted, the veteran and his representative should be furnished with a supplemental statement of the case regarding the development undertaken in the subsequent determination. They should also be afforded a reasonable period of time in which to respond. The records should then be returned to BVA for further appellate consideration. No action is required by the veteran until he receives further notice. ALBERT D. TUTERA 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) (1992).