Documentation Guidelines

Documentation must include the following components:

• Completed by a licensed or credentialed examiner (non-family member)
• A description of the disability, including the diagnosis and history
• A description of the current impact in daily living and in an educational setting
• A description of the expected duration, frequency, severity, and progression of the condition
• A description of the past use of disability services.

Examples of disability documentation include:

• Psychological, or medical records;
• Reports and assessments created by healthcare providers, psychologists, or an educational system;
• Documents that reflect education and accommodation history, such as Audiology Reports and Vision Assessments;
• Verification form of a disability (see specific guidelines and forms);
• Statement from a health or other service professional;
• Vocational Assessment

Please keep the following in mind:

Disability is defined by federal disability laws as an impairment that substantially limits one or more major life activities. Major life activities include, but are not limited to: sensory conditions, walking, learning, concentrating, communicating, and speaking.

Submit your Disability Self-Disclosure Form and disability documentation early enough to allow sufficient time for a review of the information before accommodations and services are expected to be implemented. Note: The process may take up to 4 weeks

We may need to ask you to provide additional information if the submitted documentation is incomplete or does not support your accommodation request.Professionals may suggest reasonable modifications, but we make the final decision about eligibility and appropriate modifications based on the essential requirements of the academic program or service.

You should keep a copy of the documentation that you submit for your personal records.

Documentation requirements may differ from other educational institutions and may not be accepted by other institutions, testing agencies, licensure exams, and certification programs. When seeking accommodations from organizations outside of the Medical University of South Carolina, please check with the specific program to determine their documentation guidelines.

Documentation Guidelines by Disability:

LEARNING DISABILITY

Each of the pages in this section provide more guidelines and, where appropriate, a form:

Medical University of South Carolina requires a current and comprehensive neuro-psychological or psycho-educational evaluation to assess eligibility for disability services and reasonable accommodations for students with learning disabilities.

Learning disability documentation must meet the standards below.

1. A current evaluation: Learning disabilities can affect an individual over the lifespan, but the determination of eligibility for disability services is based on the current impact on academic performance. Evaluations must include age-appropriate testing (for most students, this would mean adult-normed testing measures).    
2. A qualified evaluator is an educational, clinical, or neuropsychologist or other relevant professionals with training and expertise in learning disability assessment. Reports must be dated, signed and include credentials and licensing information of the evaluator.
3. A comprehensive history of the presenting problems describing the impact the disability has had on the individual’s learning and other major life activities.
4. A description of any record of prior use of educational support, accommodations, auxiliary aids and their efficacy.
5. A complete assessment of learning in the relevant areas listed below using the most recent edition of each instrument and a comparison to the adult norm-referenced group. Include an appendix with all scores obtained during the course of the evaluation, including scaled and percentile scores.
   • Aptitude/Cognitive Ability
   • Achievement
   • Cognitive and Information Processing including memory, processing speed and cognitive fluency,
   • Attention and Executive Functioning
   • Sensory-perceptual functioning
   • Motor functioning
   • Psychiatric, personality and behavioral assessments based on the student’s presentation and history
6. A diagnosis made using the American Psychiatric Associations Diagnostic and Statistical Manual – V (DSM-5).
7. A clinical summary including the following:
   • A demonstration that the evaluator has ruled out alternative explanations for academic problems (as a result of poor education, poor motivation and/or study skills, emotional problems, attentional problems or cultural/language differences).
   • A description of patterns in the student's cognitive ability, achievement, and information processing that support the diagnosis of a learning disability.
   • Observations of behavior during the evaluation which may have helped to form the diagnostic impression.
   • Recommendations for reasonable accommodations, including a rationale for each, linked to specific test results.

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

Medical University of South Carolina requires current and comprehensive disability documentation to assess eligibility for disability services and reasonable accommodations for students with ADHD.

ADHD documentation must meet the standards below:

1. Documentation must be current
   Eligibility for disability services at the post-secondary level is based on clear evidence of the current impact of the disability. ADHD (adult psycho-educational evaluation) must include age-appropriate diagnostic measures (for most students, this would mean adult-normed testing measures) and data of ongoing ADHD symptoms that substantially impair functioning in two or more settings (e.g., home, school, work, extra-curricular activities).
2. The evaluation must be conducted by a qualified evaluator (Psychiatrist, Neurologist or Psychologist)
   Professionals conducting assessments and rendering diagnoses of ADHD and making recommendations for accommodations must be qualified to do so. Comprehensive training and relevant experience in differential diagnosis and the full range of psychiatric disorders are essential. The name, title, and professional credentials of the evaluator should be clearly stated in the documentation. All reports should be on letterhead, typed, dated, and signed. Documentation completed by a family member will not be accepted.
3. Evidence of Impairment
   
   ADHD is defined by the DSM-V TR as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development as characterized by inattention and/or hyperactivity.
   • Childhood onset: Documentation must include a clinical summary of objective historical information that establishes symptomatology indicative of ADHD during childhood and adolescence as gathered from a developmental and family history. A thorough academic history including educational records including transcripts, report cards, teacher comments, tutoring evaluations, and past psycho-educational testing, and third-party interviews when available.
   • Current Impairment: Provides a description of current functional limitations that are a direct result of problems with attention, executive functioning, and emotional regulation deficits. Provide a description of the efficacy of academic accommodations that have been utilized by the student. Relevant employment history and use of accommodations (if applicable). Use of medication and therapy to address symptoms and the effectiveness of treatment.
4. Assessment for Academic Accommodations: The disability documentation must demonstrate the current impact of ADHD on learning and the ability to function in an academic setting. Assessment measures should be administered to demonstrate how functioning is impaired in the relevant areas for the student including: cognitive ability, processing speed, fluency, working memory, reading speed and comprehension using timed and untimed measures, attention, and executive functioning.

Test scores should be provided for all measures.

Test scores or subtest scores alone are not to be used as the determining factor for the diagnosis. Checklists and/or surveys can supplement the diagnostic profile but are not sufficient for eligibility for academic modifications. The data and clinical observations must serve to support a substantial limitation in learning for which the individual is requesting an accommodation(s).

The report must include an interpretation of the findings based on historical information, observation, and diagnostic findings. The evaluator must investigate and rule out alternative explanations resulting from medical conditions, other psychological disorders, as well as educational and cultural factors affecting the individual that may result in the individual experiencing ADHD symptoms.

Diagnostic Statement:

The report must include a specific diagnosis of ADHD (including the sub-type) based on the DSM-V TR diagnostic criteria including information regarding:

• A description of the severity and frequency of symptoms of inattention and/or hyperactivity/impulsivity that are present in two or more settings (e.g., at home, school, work, with friends or relatives; in other activities).
• Evidence that the symptoms significantly impair functioning of social, academic, or occupational functioning.

Given that many individuals benefit from prescribed medications and therapies, a positive response to medication by itself does not confirm a diagnosis, nor does the use of medication in and of itself either support or negate the need for accommodation.

Recommendations

The evaluator must describe the severity and impact of ADHD on the individual, including the manner in which the condition is substantially life limiting. The diagnostic report may include specific recommendations for accommodations that are appropriate at postsecondary level. A detailed explanation as to why each accommodation is recommended must be provided and must correlate with specific functional limitations determined through the diagnostic interview, observation, and/or testing.The evaluation must distinguish between the clinically significant behaviors of a person with ADHD from the normal behaviors of college students that include procrastination, disorganization, distractibility, restlessness, boredom, academic under-achievement and/or failure, low self-esteem, chronic tardiness, or problems with attendance.

PSYCHIATRIC DISORDERS

In addition to the information described in the General Guidelines, a request for accommodations, on the basis of a psychiatric disorder should include the following:

1. A report of evaluation by a qualified professional (Non-family member)
   • A comprehensive psychiatric or psychological evaluation should adhere to current professional standards (e.g., the current version of the American Psychiatric Association’s Practice Guidelines for the Psychiatric Evaluation of Adults) and should include the following:
   • A description of the presenting problem(s) and symptoms, with details about the onset and history of symptoms, as well as their current frequency, severity, and duration, etc.
   • Information about the individual’s current daily life activities (e.g., school, working, home, social, etc.) and day-to-day functioning relative to the general population.
   • Relevant aspects of the individual’s history, with details regarding any past or present impact of psychiatric symptoms on academic, occupational, and social functioning.
   • It is up to each evaluator to determine an appropriate assessment battery for any given evaluation. Provide assessment data and findings from all diagnostic tests and measures administered. Examples of common tests and measures include:
     • Structured diagnostic interviews/clinical interviews (e.g., Structured Clinical Interview for DSM-5 (SCID-5)).
     • Standardized norm-referenced measures of cognitive or neuropsychological functioning.
     • Behavior or symptom rating scales (e.g., current versions of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Beck Depression Inventory (BDI), Multiscore Depression Inventory for Adolescents and Adults (MDI), Beck Anxiety Inventory (BAI), Depression Anxiety and Stress Scales 21, Minnesota Multiphasic Personality Inventory (MMPI), Conners’ Adult Rating Scale, Achenbach Adult Self Report for Ages 18-59, Achenbach Behavior Checklist for Ages 18-59, Clinical Assessment of Depression, Test Anxiety Inventory, or other scales for anxiety, mood, trauma, or related symptoms).
     • Rating scales and other diagnostic instruments are not meant to be used in isolation; no one measure is considered sufficient by itself to make a psychiatric diagnosis.
     • Symptom severity indices.
     • Objective tests of effort (e.g., symptom validity tests).
     • A thorough summary that integrates test and assessment data with clinical presentation, behavioral observations, relevant background/historical information, and current functioning.
     • Evidence of a differential diagnosis and a description of how each possible alternative explanation for the identified problem has been systematically ruled out. For example, symptoms of the diagnosed psychiatric disorder must be distinguished from normal adult reactions and behaviors such as test anxiety, academic underachievement or failure, bereavement, personality traits, or low self-esteem.
     • A specific diagnosis based on criteria for psychiatric disorders consistent with the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Statistical Classification of Diseases and related Health Problems (ICD).
     • A clear description of how the identified impairment and related symptoms are relevant to the specific examination setting and context.
     • A rationale for each recommended test accommodation.
2. Objective records of impaired functioning
   • Records that reflect the individual’s functioning in daily life activities (e.g., social, academic, occupational environments, etc.) since the onset of the psychiatric disorder and at the present time.
   • A report of evaluation or treatment summary should be recently completed to establish the extent of current impairment and need for accommodations at the present time.

Essential Components of Mental Health Disability Documentation

Disability documentation must include the following elements:

1. Credentials of the evaluator
   Disability documentation must be provided by a licensed or credentialed professional with relevant training and experience. Professionals conducting assessments and rendering diagnosis of psychiatric disorders must have training in differential diagnosis and the full range of psychiatric conditions.The following professionals would generally be considered qualified to evaluate and diagnose psychiatric disorders (provided they have comprehensive training in differential diagnosis and direct experience with an adolescent and/or adult populations):
   • Licensed clinical psychologists
   • Licensed clinical social workers
   • Psychiatrists
   • Licensed Professional Counselors
   • Doctorial Level Nurse Practitioner with Psychiatric Mental Health Credentials (DPN, PMHNP)
     
     The name, title and professional credentials of the evaluator should be clearly stated in the documentation. Reports should be on letterhead, typed, dated and signed. Disability documentation may not be provided by an individual who has a personal relationship with the student.
2. Current statement of diagnosis
   Disability documentation must include a current diagnostic statement (DSM-5 or ICD 10) and should include the current overall level of severity of the condition, along with an assessment of all relevant symptoms. Accommodations are based on an assessment of the current nature and impact of a disability. Mental health conditions may change over time; therefore, current evaluations are critical for providing reasonable accommodations. In general, this means that evaluations must have been completed within the last 2 years prior to accommodation requests. In addition, depending on the nature of the student’s disability, evaluations may need to be updated each semester or year in order to determine continued eligibility.
3. Comprehensive Evaluation
   • Description of the diagnostic methodology
     The documentation must include a description of the diagnostic criteria for the condition and the evaluation method used to render a diagnosis, including medical examinations, formal testing instruments, structured interviews, and observations. The dates of administration must be included, and all scores given as standard scores and percentiles.
   • Relevant history
     The documentation must include history regarding onset, symptoms, recurrences, hospitalizations, and treatment of the current or related condition(s).
   • Assessment of Functional Limitations
     Provides a comprehensive description of the impact of the condition on the student in an academic environment, at home and in social situations. This description must provide evidence that the student is substantially limited in one or more major life activities. Consider the severity of the impairment and its symptoms, frequency and expected duration of symptoms and impact on everyday activities in determining “substantially limiting.”
   • Treatment/medication and prognosis
     Describes the current impact of medication and/or treatment and the anticipated prognosis. Describes the treatment plan. If relevant, provide information about the cyclical or episodic nature of the condition and/or potential triggers that may intensify symptoms.
4. Accommodation recommendations
   It is helpful for the evaluator to recommend accommodations or services in a post-secondary academic setting that will address the functional impact of the condition or its treatment. Accommodation recommendations should be directly connected to the limitations caused by the condition. If accommodations have been used in the past, include a description of the accommodations and information regarding their efficacy. Accommodations are provided to modify, adjust or eliminate a barrier to a course or program to ensure equitable access.