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What suggestions do you have for completing an MSR when a client refuses to provide personal historical information (such as about family, friends, experiences, etc) and it appears related to their disorder?

What suggestions do you have for completing an MSR when a client refuses to provide personal historical information (such as about family, friends, experiences, etc) and it appears related to their disorder? in topic Medical Summary Report (MSR)

Answer

If a person is guarded when you are interviewing them for the MSR, you can explain to them the importance of you gathering this information and providing it to Social Security as part of the SSI/SSDI application process. If they still don't want to provide you information then you can document in the MSR the person's guarded nature, their behavior and symptoms you observe, and document that you believe it to be due to the symptoms of their mental illness (paranoia, delusions, suspiciousness, etc.). You can try to obtain the information you need for the MSR from the person's medical records and if they are willing to sign ROIs, you can attempt to interview collateral sources such as family, friends, case managers, etc. to obtain information to include in the MSR.