What should be included in a note for a patient with spina bifida applying for Supplemental Security Income (SSI) disability benefits to document their disability during an appointment?

From the Research

For a disability evaluation note for a patient with spina bifida applying for SSI, your documentation should be comprehensive and objective, including a detailed history of the spina bifida diagnosis, functional limitations, and treatments received, as outlined in the most recent guidelines 1. When documenting the patient's history, include the type of spina bifida (myelomeningocele, meningocele, or occulta), level of lesion, and age at diagnosis.

• Document all functional limitations resulting from the condition, such as:
  • Mobility restrictions
  • Neurological deficits
  • Bowel/bladder dysfunction
  • Cognitive impairments
• Include objective physical examination findings, such as:
  • Motor strength
  • Sensation
  • Reflexes
  • Gait assessment
  • Presence of deformities
• Detail all treatments received, including:
  • Surgeries
  • Medications (specific names and dosages)
  • Assistive devices
  • Therapies
• Document secondary complications, such as:
  • Hydrocephalus
  • Tethered cord
  • Orthopedic issues
  • Pressure ulcers
• Assess activities of daily living limitations and impact on work capacity, as discussed in recent studies 2, 3.
• Include recent diagnostic studies (MRIs, urodynamics) and specialist consultations, and be specific about frequency and severity of symptoms, avoiding subjective terms in favor of measurable descriptions, as recommended in the orthopedic guidelines for the care of people with spina bifida 1.