Citation Nr: 1332349 Decision Date: 10/18/13 Archive Date: 10/24/13 DOCKET NO. 12-05 967 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD J. Honan, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1990 to June 1991. He also completed reserve service through March 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which granted service connection for PTSD and assigned a 30 percent rating, effective September 25, 2009. In addition to the paper claim file, there is a virtual file that did not contain any additional evidence. 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 Further development is warranted. A letter from the Veteran's private psychiatrist, Dr. Hoeper, dated February 2013 and received by the RO in July 2013, reflects that the Veteran had PTSD symptoms that were not noted during the July 2012 VA examination. Specifically, Dr. Hoeper observed new symptoms such as memory impairment, monthly panic attacks, and hallucinations, and placed the Veteran on three new medications. The additional evidence from Dr. Hoeper suggests that the Veteran's disability may have worsened since the last VA examination. The RO must arrange for the Veteran to undergo a VA mental disorders examination by an appropriate professional at a VA medical facility. Further, the record reflects that there are outstanding pertinent private treatment records. Although the Veteran provided VA with a July 2013 authorization to obtain records from the Goldsboro Psychiatric Clinic (Dr. Hoeper), the claim file does not contain any such records or reflect that VA attempted to obtain them. Although two letters, dated August 2009 and May 2011, from Ms. Glogau at Psychological Consulting Services are associated with the record, no treatment notes from that provider appear in the claim file. The evidence of record also indicates that employment records may be pertinent to the Veteran's claim. VA examiners have noted some level of occupational impairment due to PTSD, and the Veteran must be asked to identify any relevant employment records. Accordingly, the case is REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claim file. 2. Direct the Veteran either to submit, or to authorize VA to obtain on his behalf, the records of Dr. Hoeper (Goldsboro Psychiatric Clinic) and Ms. Glogau (Psychological Consulting Services). If those records cannot be located, a negative response must be issued and associated with the claim file. 3. Direct the Veteran either to submit, or to authorize VA to obtain on his behalf, his employment records. If those records cannot be located, a negative response must be issued and associated with the claim file. 4. Then, schedule the Veteran for a VA mental disorders examination with an appropriate professional to determine the current severity of his PTSD. The entire claim file must be made available to the examiner and the examination report must include discussion of his documented assertions and medical history, including his private treatment records. All indicated tests and studies must be accomplished and all clinical findings must be reported in detail. The examiner must render specific findings with respect to the existence and extent of any PTSD symptoms. The examiner must provide a multi-axial diagnosis, including assignment of a GAF score. Finally, the examiner must discuss whether there has been any change in the severity of the Veteran's PTSD since the last July 2012 VA examination. The examiner must set forth all findings and test results, along with a complete rationale for the conclusions reached. 5. Then, readjudicate the claim, to include consideration of any appropriate staged ratings. If the claim is not granted in full, provide the Veteran a supplemental statement of the case (SSOC) and allow an appropriate period of time for response. Thereafter, return the case to the Board. 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 that are 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. 2012). _________________________________________________ RONALD W. SCHOLZ 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 the appeal. 38 C.F.R. § 20.1100(b) (2013).