You can use these tips as a final checklist before finalizing the disability documentation you are preparing for a client or patient.
- Documentation should:
- be typed or printed on letterhead, dated, signed and be legible, including your name, title and professional credentials.
- be recent; it should be no more than 5 years old for LD and ADHD and 12 months for psychiatric disabilities.
- include the reason for referral.
- include a list of all the tests that were used to establish the disability and to support the accommodation requests. Evaluation measures selected for the assessment battery should be reliable, valid and age appropriate.
- include developmental, educational and medical histories.
- The diagnostic report should:
- have a clear statement of the disability.
- include a "rule-out" statement.
- provide appropriate measures of achievement.
- Test results should be clearly stated with all subtests noted.
- The clinical summary should recap the high points, rule out alternative explanations and summarize how the findings support any "substantial limitation" to a major life activity.
- Support for the requested accommodations must be tied to specific test results.
- Support for extended testing time should be specifically addressed by the evaluator.