Guidelines for documenting medical conditions

1. 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 presented on the professional's letterhead, typed, dated, signed, and legible
• Evaluator may not be a family member

2. 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 health care professional completed within the past 12 months is considered current, unless the condition is permanent/unchanging. The documentation may need to be updated annually so we can best accommodate the student.

Must be comprehensive: Medical disabilities include many conditions. Many conditions are changeable in nature and sometimes difficult to categorize. Documentation must therefore 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 history of presenting symptoms and relevant medical history

• 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 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 working 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 such as records of previous accommodations, high school IEPs, previous medical evaluations, and parent, teacher, tutor or employer reports can assist in better understanding and accommodating the student with a chronic health disability.