Module 5 Documentation Overview Guidelines Types of Documentation

Module 5: Documentation

Overview • Guidelines • Types of Documentation • Best Practices • Learning Check

Documentation Guidelines • Postsecondary institutions may request a reasonable level of documentation • Documentation required should not be unduly burdensome on or discouraging to the student • The documentation process must be accessible to all students and allow for flexibility as needed • Current and relevant, but not necessarily “recent” – depends on the nature of the disability

Types of Documentation • Primary – Student Self-Report • Necessary to fully understand the student’s limitations and provide appropriate accommodations • Secondary – Observation and Interaction • Disability professionals are experts for a reason, and should use their professional judgment to evaluate a student’s needs and recommend appropriate accommodations • Tertiary – External or Third Party • Educational or medical records, reports, and assessments • Helpful in establishing background, developing recommendations, and verifying diagnoses

Best Practices • Documentation should include a diagnosis from a professional capable of establishing that diagnosis • Example: An unlicensed counselor cannot diagnose a mental illness, but a licensed clinical social worker or psychologist can • How old documentation can be should be based on what the disability is and whether it is a chronic or temporary condition • Examples of temporary conditions are learning disabilities and some mental health concerns, especially if the student is receiving ongoing treatment • Documentation should be updated periodically for temporary conditions • Some professionals may indicate either a specific date or general time frame for when the condition will be reassessed

Best Practices (Continued) • IEPs or 504 plans may be considered sufficient documentation for a learning disability if a qualified diagnostic professional has signed off on the paperwork and provided a diagnosis • Psychological evaluations are considered the documentation standard for learning or other developmental disabilities • IEPs and 504 plans are valuable documentation to provide a background of what accommodations the student has received in the past

Learning Check #1 • A student provides you with an IEP which contains a diagnosis for a learning disability and accommodations, signed off by school leadership, the student, and the parent. What further documentation might be necessary? • A. A psychological evaluation from a diagnostician (e. g. psychologist) • B. Medical paperwork from a treating physician • C. Either A or B • D. No further documentation is necessary

Answer for #1 • Either A or B

Learning Check #2 • The paperwork required in the previous scenario would be examples of what type of documentation? • A. Primary • B. Secondary • C. Tertiary • D. Quaternary

Answer for #2 • Tertiary

Learning Check #3 • Postsecondary institutions may request a _______ level of documentation from the student • A. Burdensome • B. Reasonable • C. Minimal • D. None of the Above

Answer for #3 • Reasonable

Learning Check #4 • A student turns in a note from her primary care physician that asks for the student to be provided with testing accommodations due to a generalized anxiety disorder. The note is written on a prescription pad. Is this sufficient to provide accommodations? • A. Yes • B. No

Answer for #4 • Yes, it is a note with a signature from a diagnostician

Learning Check #5 • A student provides you with a discharge note from a hospital with several diagnoses present. What further information would be necessary to establish accommodations? • A. The student’s self-report of how the disability limits them • B. A detailed letter from the original diagnostician covering what testing was used to establish the diagnosis • C. Your own understanding of the disability based on research and previous student experience • D. None of the above

Answer for #5 • Both A and C

References • AHEAD. (2012, October). Supporting accommodation requests: guidance on documentation practices. Huntersville, NC: Association on Higher Education and Disability.