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.