General Guidelines for Documentation Providers
1. A diagnostic statement identifying the condition(s).
As appropriate, include ICD or DSM codes, the date of the most recent evaluation, or the dates of evaluation performed by referring professionals. If the most recent evaluation was not a full evaluation indicate when the last full evaluation conducted.
2. Current functional impact of the condition(s).
The current functional impact on physical (including mobility dexterity, and endurance), perceptual, cognitive (including attention, distractibility and communication), and behavioral abilities should be described as clinical narrative and/or through the provision of specific results from the diagnostic procedures. Descriptions should provide a sense of severity, information on variability over time or circumstance and potential environmental triggers.
3. Treatments, medications, assistive devices/services currently prescribed or in use.
A description of treatments, medications, assistive devices, accommodations and/or assistive services in current use and their estimated effectiveness in ameliorating the impact of the condition(s) is helpful. Include any significant side effects that may impact physical, perceptual, behavioral or cognitive performance.
4. The expected progression or stability of the impacts described over time.
This description should provide an estimate of the change in the functional impacts of the condition(s) over time and/or recommendations concerning the predictable needs for reevaluation of the condition(s). If the condition is variable (based on known cycles or environmental triggers) are they under self‐care for flare‐ups or episodes?
5. Recommended accommodations and services.
Recommendations should be logically connected to the impact of the condition. When connections are not obvious they should be explained. Recommendations will be deferred to whenever possible but will be evaluated in the context of the course or program. Not all documentation will contain all of these elements, but the more information we have, the easier it is to determine which accommodations are appropriate and beneficial.
For convenience, The Office of Accommodative Services provides a “Disability Verification Form” for medical, sensory, and mental health providers.
Also of interest: The U.S. Department of Education Office for Civil Rights has issued a pamphlet, "Students with Disabilities: Preparing for Postsecondary Education: Know Your Rights and Responsibilities." The pamphlet is found at http://www.ed.gov/ocr/transition.html.