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Does the medical summary report have to be in sections? For example, does the legal history have to be in a seperate section or paragraph from the medical history?
We recommend using headings throughout the MSR to divide information so that DDS can quickly find the evidence they are looking for. These headings typically include: personal history, employment, physical health, psychiatric health, and functional information. You can include sub-headings in these categories to further organize the information if you’d like.
Naturally, information may overlap in some of the sections. For instance, in legal history you may talk about how an applicant’s incarceration was related to their symptoms and then add extra information about symptoms in medical history. In these areas of overlap, there’s no need to repeat information you have already provided. By avoiding excessive repetition in the MSR and grouping the information using broad headings, we can help walk DDS through the documentation of how the applicant meets the disability criteria.
The SOAR TA Center is available to review Medical Summary Reports from SOAR practitioners. To submit your MSR for review, email firstname.lastname@example.org and attach your MSR with the applicant’s name, birthdate, and Social Security number removed for HIPAA compliance.
I cannot find the template or blank file for MSR. Should I just create a word document following the rubric?
The Medical Summary Report (MSR) Interview Guide and Template is a great tool for writing the MSR. The Interview Guide portion contains key questions to ask applicants when gathering evidence for the application. The Template contains main headings that may be used when formatting the MSR. Be sure to remove the Interview Guide and guidance under the Template headings before turning the MSR in to DDS. It is also important to put the MSR on your agency's letterhead whenever possible.
This guide and template can be found on the SOAR Tools and Worksheets page.View
The physician in my clinic refuses to read or sign my Medical Summary Report. What do I do?
It is unfortunate when we run across physicians who are unwilling to help people access the benefits that they are entitled to, although it is a common problem. Many doctors will say that they have not seen a person enough to support a report such as the MSR. Sometimes doctors on ACT (Assertive Community Treatment) teams or in PSR (Psychosocial Rehab) programs may be willing to co-sign reports. When you can’t find a doctor to cosign the report, we recommend you submit the MSR as collateral information along with the medical records that you have collected that document the diagnostic information from a physician.
You may want to find out why they are refusing to sign the report. Is it because they feel they don't know enough to sign it? Or that it wasn't written by them so they don't want to sign it? Are there other reasons? One of the things we find is that the doctors often misunderstand what we are asking them to do. They believe that, by signing the report, they are "approving" the person for disability benefits. DDS makes that decision. What they're doing is simply attesting that the information contained in this report is true. It's fine if they even write a statement that they believe the information in this report is true.
You might remind the doctor and the clinic/hospital that when someone is approved for SSI/SSDI they are also going to be eligible for Medicaid/Medicare which means retroactive reimbursement for services provided and ongoing payment for treatment and services in the future.
One SOAR program contacted the state medical association for the names of retired physicians and asked if anyone was willing to do one assessment pro-bono. It was fairly successful.View
If someone asks for a copy of their Medical Summary Report, do you give them a copy ?
The short answer is "yes." If someone asks to see their Medical Summary Report, you can provide it to them in the same manner that your agency would release a copy of their medical records to them.
However, there are some other factors to keep in mind. Since the MSR focuses on an applicant's symptoms and functional limitations rather than their strengths, we recommend talking with them first to explain that the report is written in this manner to demonstrate how they may be eligible for SSI/SSDI and that SSA needs to see numerous examples of their limitations. Remind them that they have a lot of personal strengths and that this report is not a full reflection of that.
It is important to speak with the applicant throughout the process in order to alleviate any concerns about what information will be included in the MSR. One best practice to establish transparency and trust is to ask permission on the first interview to take notes. Tell the applicant that at any time they can ask you to stop taking notes or to see what you are writing. Emphasize that your goal is to capture their words so that they can tell their story to SSA through this process. Ultimately, the MSR is comprised mainly of their quotes and information they have provided to you.
Reading about one's symptoms and limitations can be very difficult and through this conversation applicants may find that they aren't prepared for that or that it would not be beneficial for their recovery. But, if after this preparation, the applicant wants to read the MSR, then that is their right to do so, following your agency's guidelines.View
When the MSR is signed by an Acceptable Medical Source (AMS) is there any HIPAA concern if the MSR contains information from other treating providers?
An MSR that has been written based on properly released records can be shared with the primary AMS. At the point of obtaining the signature, it is primarily a privacy issue, not HIPAA. However, it would be a best practice to have a release signed by the applicant permitting the case worker to communicate with the AMS.View
Can an Acceptable Medical Source (AMS) sign the Medical Summary Report if the client's main disabilities are mental but the AMS has mainly treated them for physical conditions?
Yes. By signing the MSR, the AMS is only indicating that they believe the included information to be true. It is likely that the provider has spoken with the individual about his/her mental illness, seen some records to that effect, and/or has witnessed some symptoms. In order to treat a patient properly for physical health conditions, the provider would need to be aware of medications and mental health treatment. If the doctor does not want to sign off on anything that does not pertain to their specific field of practice, they could sign a reduced MSR that does not include reference to the other treating sources, but does include reference to all of the conditions that the doctor feels comfortable attesting to.View
How do I get started writing the medical summary report? It is so intimidating.
Trying to write the Medical Summary Report (MSR), a key component of the SOAR approach, can seem challenging at first. Everyone is going to have a different approach to writing that works for them.
We recommend starting with the Medical Summary Report Worksheet as a template. Work on only one section in each sitting. Breaking it up into smaller chunks can take some of the pressure off of writing a long report. It may also help if you don't set a target length. Think about just writing a letter that tells all you know about someone's Personal History, Psychiatric History, or Functional Information. If you can get a couple sections complete and then put them together, you will likely see that the MSR comes together easier than you anticipated.
For more information about Medical Summary Reports, see the SOAR Library.View
Is it necessary to have a psychiatrist conduct the Mental Status Exam (MSE) on an applicant or will a licensed social worker suffice?
The Mental Status Exam must be performed by an "Acceptable Medical Source" (AMS) in order to establish a "medically determinable physical or mental impairment."
Acceptable Medical Sources include physicians, psychologists, advanced practice nurse practitioners (APRN), or physician assistants (PA). Further, the APRN category includes: Certified Nurse Midwife, Nurse Practitioner, Certified Registered Nurse Anesthetist, and Clinical Nurse Specialist. Audiologists are also acceptable medical sources for hearing-related disorders.
Licensed Clinical Social Workers (LCSWs) are not included.View
I'm working with a client who has indicated that both her treating psychiatrist and her primary care doctor are willing to sign the MSR. Is there any advantage to having 2 signatures? Could this cause any issues?
It's great that she has two doctors willing to sign! Yes, we recommend including both signatures -- it sends a stronger message that they are both on board with the content. And it won't cause any issues.View
Is there a sample MSR for adults with a physical disability?
Many of our sample MSRs include information about physical disabilities in addition to mental impairments. Here is an example of one.
We also encourage you to review the Listings for the specific criteria SSA will be looking for, for each condition. You'll want to include information in your MSR about how the person's conditions meet the listing criteria.View