Current course:  SSI/SSDI Outreach, Access, and Recovery (SOAR) Online Course: Adult Curriculum

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 applicant’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) 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.
 
In some states or specific Field Offices, SSA and DDS have agreed, as part of the SOAR Process, that the MSR can take the place of the SSA-3373: Function Report. Even if the SSA-3373 is required, the MSR is included as part of the SOAR packet as additional evidence to support the claim. (For more information, read About the Function Report: SSA-3373).
 
cartoon male Super SOAR figure
SOAR Tip: DDS may also ask the applicant to complete an SSA-3369 Work History Report or an SSA-821 Work Activity Report, if the applicant worked after the alleged onset date. Read the articles on these forms for more tips on how to fill them out!
Organizing the MSR
We strongly urge you to use the SOAR MSR 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 eight sections, which are summarized in the table below
 
Writing the MSR
Your goal is to help the DDS examiner to “see” the person.
  • The challenge is to transform information you’ve collected into a vivid picture of the person and his/her functional abilities
  • Remember to directly quote the applicant 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 applicant 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 applicant or medical records when presenting your evidence, rather than paraphrasing what he or she says.
 
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 a physician, psychologist, advanced practice nurse practitioner (APRN), or physician assistant (PA) who has seen the applicant and reviewed the report.
    • Audiologists are also acceptable medical sources for hearing-related disorders
 
Co-Signature
While physicians, psychiatrists, psychologists, APRNs, and PAs are acceptable medical sources for diagnostic purposes for SSA, it is not necessary for them 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 physician 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
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 applicant’s symptoms and functioning
  • All of the applicant’s physical and mental health diagnoses

II. Personal History

  • Current and past living situations and homelessness history
  • Family background and marital/intimate relationships, as they relate to the applicant’s conditions and functioning
  • Trauma/victimization, if it relates to the applicant’s conditions and functioning
  • Educational history, including information on learning difficulties, grades repeated, special education, relationships with other students/teachers
  • Legal history as it relates to symptoms of their illness, with information about treatment in jail/prison

III. Occupational History

  • Employment history for the past 15 years, including all jobs, reasons for leaving, job skills, problems with task completion and relationships with supervisors/co-workers
  • Military service history, including any trauma as it relates to the applicant’s illnesses or functioning
  • References to Vocational Rehabilitation evaluations or Individual Placement and Support (IPS) job reports

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 applicant’s symptoms while sober
  • If the applicant 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 applicant’s ability to sit/stand/walk/carry objects

VI. Psychiatric History & Treatment

  • 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*

  • Understand, remember, or apply information
  • Interact with others
  • Concentrate, persist, or maintain pace
  • Adapt or manage oneself
  • Address all four areas of mental functioning, even if the applicant does not display limitations in all areas
VIII. Summary
  • Brief summary of the evidence provided, restating the diagnoses provided in the introduction
* On January 17, 2017 SSA enacted updates to the mental disorder listings and areas of mental functioning. More information about the updates can be found throughout the SOAR Online Course.