Documentation Guidelines

 

Documentation

Guidelines

Documentation consists of an evaluation by an appropriate professional that relates the current impact of the condition to the requester. Documentation should include: A diagnostic statement including date of most recent evaluation The current impact of (or limitations imposed by) the condition Treatments, medications, devices or services currently prescribed or used to minimize the impact of the condition The expected duration, stability, or progressing of the condition

The following can be used to guide the professional and student for providing adequate documentation. The evaluator must attach copies or summaries of the specific tests, measures or clerical data used to establish each criteria, and include his/her signature. Attention Deficit/ Hyperactivity Disorder (ADD/ADHD) Documentation Guidelines Deaf and Hard of Hearing Documentation Guidelines Head Injury/Traumatic Brain Injury Documentation Guidelines Learning Disability Documentation Guidelines Physical, Medical and Mobility Impairment Documentation Guidelines Psychiatric Disabilities Documentation Guidelines Vision Documentation Guidelines