Skip to main content

SOAR Critical Component: The Medical Summary Report

The Medical Summary Report (MSR) is SOAR’s signature tool and key to a successful application. It provides a succinct, comprehensive summary of the child’s personal and treatment history and its impact on his or her life. It also clearly describes the factors affecting functioning and ability to work.

The Medical Summary Report (MSR)

The Medical Summary Report (MSR) is a letter written by the case manager and submitted as part of the SOAR application packet. The skills you practiced in writing functional descriptions will be put to use in your MSR letter. View sample MSRs here.

Organizing the MSR

We strongly urge you to use the SOAR MSR Interview Guide and Template to help you organize information as you gather it.

  • The structure of your MSR should follow the same structure as the template.
  • The template is organized into seven main sections and a summary, which are summarized in the table below.

Writing the MSR

Your goal is to help the DDS examiner to “see” how the child functions.

  • The challenge is to transform information you’ve collected into a vivid picture of the child and their functioning as compared to children of the same age who do not have impairments.
  • Remember to directly quote the child and parent or caregiver wherever possible.
  • Be sure to attach any referenced documents to your report.

Avoid Using Opinions in the MSR

DDS examiners are looking for factual evidence based in the medical records, progress notes, quotes from your interviews, observations made and collateral information.

  • Avoid using your own opinions in the MSR or projections about what might happen in the future.
  • For example, it would be inappropriate to write, “The MSR shows that this child is clearly disabled,” because it is DDS’s responsibility to make that decision.
  • Make connections between the symptoms and functional impairments but do not analyze or judge what that means.
  • To avoid inserting opinions, it is often helpful to rely on direct quotes from the parent, child, or medical records when presenting your evidence, rather than paraphrasing what he or she says.
  • Remember, you are describing how the child’s functioning compares to the functioning of children of the same age who do not have impairments.

Summary and Signing the Report

At the end of the MSR, write a brief summary of the evidence presented and sign the report.

  • Be sure to provide your contact information.
  • If possible, have it co-signed by an acceptable medical source who has seen the child and reviewed the report.

Acceptable Medical Sources for Child SSI Claims

  • Licensed physicians (medical or osteopathic doctors)
  • Licensed or certified psychologists (including school psychologists)
  • Licensed Advanced Practice Registered Nurses (APRNs)
  • Licensed Physician Assistants (PAs)
  • Licensed optometrists for the measurement of visual acuity and visual fields
  • Licensed podiatrists for impairments of the foot or ankle only
  • Qualified speech-language pathologists for speech or language impairments only
  • Licensed audiologists for impairments of hearing- loss, auditory processing disorders, and balance disorders

Co-Signature

While SSA requires evidence from physicians, psychiatrists, psychologists, school psychologists, APRNs, or PAs (“acceptable medical sources”) to establish a medically determinable impairment, it is not necessary for an “acceptable medical source” to write the MSR.

  • However, a co-signature by an acceptable medical source raises the MSR from “collateral information” to “medical evidence.”
  • When asking a treating medical provider to co-sign your report
  • A well-written MSR is an essential part of the SOAR Application Packet, even if a co-signature is not available.
The Medical Summary Report Sections
Section Content
I. Introduction
  • Identifying information: name, date of birth, and Social Security number
  • Physical description, including behavior, mannerisms, and dress
  • Information and observations that illustrate the child’s symptoms and functioning
  • All of the child’s physical and mental health diagnoses
II. Personal History and Family Background
  • Current and past living situations and homelessness history
  • Family background as it relates to the child’s conditions and functioning
  • Trauma/victimization and adverse childhood experiences
  • Legal history as it relates to symptoms of their illness, with information about treatment in juvenile detention
  • Connections with other systems (child welfare, juvenile justice, child behavioral health)
III. Educational History
  • Educational history, including information on learning difficulties, grades repeated, special education, relationships with other students/teachers
  • Current school placement and functioning at school; special education services; school disciplinary reports
  • School Vocational Plans, competitive or sheltered work experience
IV. Substance Use
  • Substance use history and treatment, including reasons for use, impact of use, treatment history, and any periods of sobriety with a focus on the child’s symptoms while sober
  • If the child has substance use treatment records, reference periods of sobriety and any corresponding symptoms or impairments
V. Physical Health
  • Brief history of symptoms and treatment, with a focus on physical health in the previous 2-3 years
  • If there is no current treatment, provide an explanation
  • Information on how the conditions impact the child’s ability to sit/stand/walk/carry objects
VI. Mental Health
  • Brief history of symptoms and treatment at all providers, with a focus on mental health in the previous 2-3 years
    • In each summary, provide reason for treatment, diagnosis, and medications
  • Summary of a current mental status exam, if available
  • Include quotes from the records that help document symptoms or functional impairments
  • If there is no current treatment, provide explanation
VII. Functional Information
  • Information and examples that document the child’s limitation in the areas and domains of functioning
  • Address all areas of mental functioning, even if the child does not display limitations in all areas
VIII. Summary
  • Brief summary of the evidence provided, restating the diagnoses provided in the introduction

Details

Type:
Adult Course
Date:
April, 2018

Other Details

Topic
Medical Summary Report (MSR)
Focus
Youth