Essential Elements of Documentation

Disability Services
 
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The credentials of the evaluator(s)
The best quality documentation is provided by a licensed or otherwise properly credentialed professional who has undergone appropriate and comprehensive training, has relevant experience, and has no personal relationship with the individual being evaluated.
 
A diagnostic statement identifying the disability
Quality documentation includes a clear diagnostic statement that describes how the condition was diagnosed, provides information on the functional impact, and details the typical progression or prognosis of the condition. While diagnostic codes (e.g., DSM, ICF) are helpful in providing this information, a full clinical description will also convey the necessary information.
 
A description of the diagnostic methodology used
Quality documentation includes a description of the diagnostic criteria, evaluation methods, procedures, tests and dates of administration, as well as a clinical narrative, observation, and specific results. Where appropriate to the nature of the disability, having both summary data and specific test scores (with the norming population identified) within the report is recommended.
 
A description of the current functional limitations
Information on how the disabling condition(s) currently impacts the individual provides useful information for both establishing a disability and identifying possible accommodations. A combination of the results of formal evaluation procedures, clinical narrative, and the individual’s self report is the most comprehensive approach to fully documenting impact. The best quality documentation is thorough enough to demonstrate whether and how a major life activity is substantially limited by providing a clear sense of the severity, frequency and pervasiveness of the condition(s).
 
A description of the expected progression or stability of the disability
It is helpful when documentation provides information on expected changes in the functional impact of the disability over time and context. Information on the cyclical or episodic nature of the disability and known or suspected environmental triggers to episodes provides opportunities to anticipate and plan for varying functional impacts.
 
A description of current and past accommodations, services and/or medications
The most comprehensive documentation will include a description of both current and past medications, auxiliary aids, assistive devices, support services, and accommodations, including their effectiveness in ameliorating functional impacts of the disability. A discussion of any significant side effects from current medications or services that may impact physical, perceptual, behavioral or cognitive performance is helpful when included in the report. While accommodations provided in another setting are not binding on the current institution, they may provide insight in making current decisions.
 
Recommendations for accommodations, adaptive devices, assistive services, compensatory strategies, and/or collateral support services
Recommendations from professionals with a history of working with the individual provide valuable information for review and the planning process. It is most helpful when recommended accommodations and strategies are logically related to functional limitations; if connections are not obvious, a clear explanation of their relationship can be useful in decision-making. While the postsecondary institution has no obligation to provide or adopt recommendations made by outside entities, those that are congruent with the programs, services, and benefits offered by the college or program may be appropriate.
 

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