Documentation Guidelines

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Disability documentation is confidential information from an appropriately certified professional who is knowledgeable about you and your condition. Such professionals include physicians, educational psychologists, therapists, mobility specialists, and rehabilitation counselors. Documentation is used to determine eligibility for disability services and accommodations.

*Documentation must be submitted in English.

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 (see: What is a Disability?).
  • 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:

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. If your documentation is not within 3 years, reach out to your licensed primary physician for a referral to obtain updated testing.

ADHD documentation must meet the standards below:

  • Documentation must be current (3 years)
    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).
  • 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.
  • 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.
  • 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.

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Essential Components of Mental Health Disability Documentation

Disability documentation must include the following elements:

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
  • other relevantly trained medical doctors
  • 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.
  • 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 six months 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.
  • 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.
  • 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.

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