Citation Nr: 1126865 Decision Date: 07/19/11 Archive Date: 07/29/11 DOCKET NO. 10-48 571 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUE Entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers WITNESSES AT HEARING ON APPEAL Veteran and R.A. ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1952 to January 1956 and from March 1956 to May 1972. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decisions of the Newark, New Jersey, Department of Veterans Affairs (VA) Regional Office (RO), which continued the 50 percent evaluation for PTSD. In January 2011, the Veteran testified at a Board hearing held before the undersigned Veterans Law Judge. A copy of the transcript is of record. The Board notes that the record was held open for 90 days; however, as of this date no additional evidence has been submitted. The issue of erectile dysfunction, to include as secondary to PTSD, has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West Supp. 2010). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND The record as it stands is currently inadequate for the purpose of rendering a fully informed decision as to the claim on appeal. Where the record before the Board is inadequate to render a fully informed decision, a remand to the RO is required in order for VA to fulfill its statutory duty to assist the Veteran to develop the facts pertinent to the claim. Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). At the January 2011 Board hearing, the Veteran reported his pending 45-day VA hospitalization treatment for his PTSD at the VA Medical Center (VAMC) in Montrose, New York. He also testified that he attended group counseling once a week at the Community Based Outpatient Clinic (COBC) in Fort Dix, New Jersey, but stopped once he was offered the hospitalization treatment at the Montrose VAMC. Furthermore, in a May 2009 treatment statement, Dr. R.R. specified that he has provided psychiatric care to the Veteran at the Philadelphia VAMC since August 2006. The Veteran confirmed receiving such treatment at the October 2009 VA examination and the January 2011 Board hearing. After review of the record, the Board finds that VA hospitalization and/or treatment records pertaining to the Veteran's PTSD from the Fort Dix CBOC and the VAMCs in Montrose and Philadelphia are not associated with the claims file. There is also no evidence to show that he failed to undergo the hospitalization treatment at the Montrose VAMC. Since VA records are considered part of the record on appeal, they are within VA's constructive possession and must be considered in deciding the Veteran's claim. Therefore, as VA has notice of the potential existence of VA hospitalization treatment records from the Montrose VAMC and VA outpatient treatment records from the Fort Dix CBOC and Philadelphia VAMC pertaining to his service-connected PTSD, they must be retrieved and associated with the other evidence already on file. See Bell v. Derwinski, 2 Vet. App. 611 (1992); see also Epps v. Brown, 9 Vet. App. 341 (1996); Robinette v. Brown, 8 Vet. App. 69 (1995). Therefore, in order to give the Veteran every consideration with respect to the present appeal and to ensure due process, this matter is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain and associate with the claims file all outstanding VA treatment and/or hospitalization records pertaining to the Veteran's PTSD from the Fort Dix CBOC and the Montrose VAMC, as well as from the Philadelphia VAMC from August 2006, the date Dr. R.R. identified that treatment began, to the present. If any requested records are not available, or if the search for any such records otherwise yields negative results, that fact should clearly be documented in the claims file, and the Veteran and his representative should be informed in writing. 2. Schedule the Veteran for an examination to determine the current severity of his service-connected PTSD. Any and all indicated evaluation studies and tests deemed necessary by the examiner should be accomplished. All objective findings pursuant to the rating criteria in 38 C.F.R. § 4.130, Diagnostic Code 9411 should be assessed and documented. The examiner should render specific findings with respect to the existence and extent (or frequency, as appropriate) of: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. The examiner must also discuss any additional symptoms, degree of social and industrial impairment, and include a Global Assessment Functioning (GAF) scale score with an explanation of what the assigned score represents. 3. Thereafter, the issue on appeal should be readjudicated. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) and afforded the appropriate time within which to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome in this case. The Veteran need take no action unless otherwise notified. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). _________________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2010).