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.
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.