Guidelines for documenting medical conditions

A qualified evaluator

Professionals using assessments to determine the diagnosis of a medical condition and making recommendations for appropriate accommodations must be qualified to do so. This should be a medical doctor qualified to assess and treat the medical condition. The documentation must meet the following criteria:

  • Include evaluator’s name, title and professional credentials.
  • Be typed, dated and signed on the professional’s letterhead.
  • Evaluator may not be a family member.

Documentation

Must be current: Reasonable accommodations are based on the current impact of a disability. It is critical that medical documentation describe an individual’s current level of functioning and need for accommodations. A full report from a treating healthcare professional completed within the past 12 months is considered current unless the condition is permanent/unchanging. The documentation may need to be updated annually in order to best accommodate the student.

Must be comprehensive: Many conditions are changeable in nature and sometimes difficult to categorize. Documentation must be thorough, giving a full picture of the individual, not simply a diagnosis. A diagnosis alone is not a basis for accommodation.

Documentation must include:

  • A discussion of:
    • A history of presenting symptoms and relevant medical history.
    • A description of current impairment.
    • A summary of assessment procedures and evaluation instruments/reports used.
    • Diagnosis duration and severity of the disorder.
    • Treatment and medication history, including medication side effects.
    • Discussion of any assistive devices and technology used.
    • Status of the individual’s condition (i.e. static, improving or degrading)
    • Expected progression of the condition over time.
  • A clear diagnosis of the medical disability with the diagnosis based on appropriate diagnostic criteria.
    • Diagnosis cannot include wording such as “seems to indicate” or “suggests.”
  • The current functional limitations of the individual in an academic environment.
  • Appropriate and specific recommendations for accommodations in the academic environment.

May include supporting information: In addition to a qualified physician’s report, other helpful documents include:

  • Records of previous accommodations.
  • High school IEP’s
  • Previous medical evaluations
  • Parent, teacher, tutor, or employer reports can also assist in better understanding and accommodating the student with a chronic health disability.