Documentation Guidelines

1. The credentials of the evaluator
   Documentation must be completed by a licensed or otherwise properly credentialed professional who has appropriate training and experience and has no close, personal relationship with the student being evaluated. A good match between the credentials of the individual making the diagnosis and the disability being reported is expected (e.g., an orthopedic limitation might be documented by a physician but not by a licensed psychologist).
    
2. A diagnostic statement identifying the disability
   Documentation must include a clear diagnostic statement identifying the disability and the date of the most current diagnostic evaluation as well as the date of the original diagnosis, as appropriate. While diagnostic codes from the Diagnostic Statistical Manual of the American Psychiatric Association (DSM) or the International Classification of Functioning Disability and Health (ICF) of the World Health Organization are helpful in providing this information, a full clinical description also can convey the necessary information.
    
3. A description of the diagnostic methodology used
   Documentation must include a description of the current diagnostic criteria, evaluation methods, procedures, tests, and dates of administration as well as a clinical narrative interpretation. Where appropriate to the nature of the disability (e.g., learning and cognitive disorders), the report should contain both summary data and specific tests scores.
   
   Diagnostic methods that are congruent with the particular disability and current professional practices in the field are expected. Methods may include formal instruments, medical examinations, structured interview protocols, performance observations, and unstructured interviews. If results from informal or nonstandardized methods of evaluation are reported, a clear explanation of their role and significance in the diagnostic process should be included.
     
4. A description of the current functional limitations
   Documentation must include information on how the disability currently impacts the individual. A combination of the results of formal evaluation procedures, clinical narrative, and the individual’s self report is the most comprehensive approach to fully documenting impact. Documentation should be thorough enough to demonstrate whether and how a major life activity is substantially limited by providing a clear sense of the severity, frequency, and pervasiveness of the disability.
     
   While relatively recent documentation is recommended in most circumstances, common sense and discretion in accepting older documentation of disabilities that are permanent or non-varying are recommended.  Likewise, changes in the disability and/or changes in how the disability impacts the individual as a result of growth and development may warrant more frequent updates to provide an accurate picture. Additionally, if changes in accommodations are needed, updated documentation may be required. In other words, the recency of the documentation depends on the facts and circumstances of the student’s disability and the accommodations requested.
     
   USM and MCC Disability Support Services offices, based on their staff members’ professional judgment, may consider accepting older documentation on a provisional basis. Accommodations may be provided in the interim, on a case-by-case basis, while the student obtains the necessary updated documentation.
     
5. A description of the expected progression or stability of the disability
   Documentation must provide information on expected changes in the functional impact of the disability over time and context, if the disability is cyclical or episodic in nature (e.g., bipolar disorder, some chronic medical conditions). Information regarding known or suspected environmental triggers to episodes can be helpful in anticipating and planning for varying functional impacts. If the disability is not stable, information on interventions (including the individual’s own strategies) for exacerbations and recommended timelines for re-evaluation are most helpful.
     
6. A description of current and past accommodations, services and/or medications
   Documentation should include a description of current and past accommodations, services, medications, auxiliary aids, and assistive devices, including their effectiveness in ameliorating functional impacts of the disability. A discussion of any significant side effects from current medications or services that may impact physical, perceptual, behavioral, or cognitive performance can be helpful. While accommodations provided in another setting are not binding on the current institution, they may provide insight in making current decisions.
      
7. Recommendations for reasonable accommodations and services
   Documentation should include recommendations for accommodations and services. Recommendations from professionals with a history of working with the student can provide valuable information for review and planning. The recommended accommodations and services should be logically related to the student’s functional limitations.
     
   While the postsecondary institution has no obligation to provide or adopt recommendations made by outside entities, those that are congruent with the institution’s courses, programs, and services may be appropriate. The postsecondary institution may substitute another accommodation if it is considered to be effective and parallel to the one recommended and/or requested. When recommendations go beyond equitable and inclusive services and benefits, they may still be useful in suggesting alternative accommodations and services.

Recommendation for Creating Disability-Specify Documentation Guidelines

While it is neither practical nor desirable to create specific documentation requirements for every condition that may be considered a disability, individual institutions may choose to establish protocols for more common disabilities (e.g., learning disabilities, ADHD). In doing so, University System of Maryland institutions and Maryland community colleges should incorporate the seven essential guidelines for quality disability documentation outlined above.

USM Guidelines for Documentation of Disability, September 2011