Citation Nr: 18157819
Decision Date: 12/13/18	Archive Date: 12/13/18

DOCKET NO. 16-62 928
DATE:	December 13, 2018
REMANDED
Entitlement to an initial rating higher than 70 percent for posttraumatic stress disorder (PTSD) is remanded.
REASONS FOR REMAND
The Veteran had active military service from October 1987 to November 1991. 
In her initial claim, the Veteran reported she received treatment after discharge, from November 1994 to March 2016, for her claimed disability from VA Western New York Healthcare System, Buffalo, New York.  Records from September 1997 to September 2016 have been associated with the claims file.  The agency of original jurisdiction (AOJ) has been unable to obtain records from November 1994 to September 15, 1997.  It appears the AOJ determined these records do not exist, but efforts to obtain such records have not been documented to show compliance with 38 C.F.R. § 3.159(c)(2), obtaining records in the custody of a Federal department.  On remand, the AOJ should follow the procedures set forth in 38 C.F.R. § 3.159(c)(2), as regards to requesting records from a Federal facility, to obtain VA treatment records from November 1994 to September 15, 1997.  All records and/or responses received should be associated with the claims file.  If it is determined that such records do not exist, render a formal finding of unavailability.
Since the Veteran’s last VA compensation examination in August 2016, her husband submitted an October 2016 statement relating his observations of her PTSD symptoms, which indicates a worsening of such symptoms.  The Board finds that more recent evidence must be obtained to determine the current severity of the Veteran’s PTSD.  An additional VA examination is therefore necessary to determine the current severity of the service-connected PTSD.  See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); 38 C.F.R. § 3.159(c)(4).
The matter is REMANDED for the following action:
1. Make another request, and additional requests as are necessary, to obtain the November 1994 to September 15, 1997 VA treatment records from VA Western New York Healthcare System, Buffalo, New York.  Follow the procedures set forth in 38 C.F.R. § 3.159(c)(2) as regards requesting records from a Federal facility.  All records and/or responses received should be associated with the claims file.  If it is determined that such records do not exist, render a formal finding of unavailability.
2. After completing the above development, schedule the Veteran for a VA mental health examination, with a psychiatrist or psychologist, to determine the nature and severity of her service-connected PTSD.  The claims file and a copy of this remand must be provided to the examiner for review.  All appropriate testing should be conducted, and all clinical manifestations of the service-connected PTSD should be reported in detail.
Specifically, the VA examiner is asked to determine whether the Veteran’s service-connected PTSD is manifested by the following:
Total occupational AND social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and, memory loss for names of close relatives, own occupation, or own name. 
The examiner should also provide an opinion addressing the functional impairment caused solely by the service-connected PTSD, to include a full description of the effects of the disability upon the Veteran’s ordinary activity.  Any opinion expressed by the VA examiner should be accompanied by a complete rationale. 
 
A. C. MACKENZIE
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	M. Young, Counsel