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Documentation: Six Core Elements


Based on a review of decisions of the Office for Civil Rights, the following six core elements of documentation should help you evaluate your current documentation:
1. Documentation should contain a clear statement identifying the area of disability
Classification codes from the Diagnostic Statistical Manual (DSM) or the International Classifications of Disease (ICD) are helpful.  Be sure the documentation includes the dates of the original diagnosis and any evaluations performed by referring professionals, along with a date and description of the most current evaluation.
2. Documentation should contain information regarding the current functional impact of the disability
A psycho-educational battery of tests consisting of standardized tests that measure aptitude, achievement, and cognitive processing is the most common approach for identifying and quantifying a learning disability, and it is likely to meet the minimum requirements for documentation at any college or university.  Current functional impact on physical, perceptual, cognitive, and behavioral abilities should be described in narrative, and when formal or informal testing was used, the details of the results should also be included.
3. Documentation should include information about treatments, medications, and assistive devices and services
While it is important to specifically describe treatments, medications, accommodations, assistive devices and assistive services that your student is currently receiving, it is also important to include a description of their estimated effectiveness in minimizing the impact of the disability.
4. Documentation should provide a description that provide information about the expected progression or stability of the disability over time
Include a description of any expected change in the functional impacts of the disability over time.  Also include information about any recommendations concerning the need for re-evaluation of the disability, especially if your student experiences flare-ups or episodes.
5. Documentation should include recommendations
Because recommendations must be reviewed and approved by the college or university, all recommendations should be directly linked to the impact of the disability.  When connections are not specific, they should be explained in detail.
6. Documentation should contain the credentials of the evaluator
If your student’s documentation does not contain a letterhead or form, be sure to include the credentials of the evaluator.  If the credentials of the evaluator are not typically associated with the diagnosis of the disability, be sure to include a brief description of the evaluator’s experience with this type of diagnosis.
Remember, in order to receive accommodations at the post-secondary level, documentation must demonstrate that your student has a disability as defined by the ADA and Section 504. Colleges grant accommodations when existing documentation clearly links the current impact of the disability to the requests your student is making.  To avoid complications, always investigate the specific documentation requirements for the colleges your student is likely to attend by either visiting the college’s website or contacting the college’s Disability Services Office.
Heather Creech, M.A. CCC-SLP
Educational Consultant


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