Documentation in School Settings: Frequently Asked Questions

These FAQs are based on excerpts from federal laws and best practice information. The information provided is not intended to be legal advice. If legal advice is needed, please contact a licensed attorney.

For additional clarification on documentation questions, check with your state or local education agency and/or refer to the applicable federal law(s). Questions about this resource can be directed to schools@asha.org.

IEPs

The following section was developed by ASHA member Barbara Moore with input from the ASHA School Services staff and other sources. We gratefully acknowledge Dr. Moore's contributions to this resource.

• Do you have to document all individualized education program (IEP) discussions in the minutes? What if parents want to add something to the minutes? What if something is not included in the minutes?
• What documentation is required when modifications to the IEP are needed?
• Can you hold an IEP meeting if parents do not attend/show?
• Is there any flexibility in documenting how often services are provided (e.g., two times per week vs. contacts per month)?
• What are the key components of a measurable IEP goal?

Treatment Notes/Records

• What constitutes an official school record? Does it include treatment notes, lesson plans, progress notes, notes to parents, personal notes, 504 accommodation plans?
• Where should official records be kept?
• How long do I need to keep student records?
• What should be included in therapy notes?
• What should be included in an assessment report?
• Can parents insert other information into an assessment report?
• How should reports from other agencies be handled?

Electronic/Other Communication

• Should e-mail communications be kept in the student file? Are they part of the "official" record? Is the same true of fax confirmations/text messages/postal receipts?
• Should telephone conversations be documented? If so, in what form should phone conversations be documented?

Test Protocols

• Where should test protocols be kept and for how long?
• Can test protocols be destroyed after the information is included in the diagnostic report/multidisciplinary team evaluation?
• Can parents see and have a copy of the test protocols?

Response to Intervention

• How should we document RTI services?

Other

• What kind of documentation is needed for home school students? What about for private school students?

IEPs

Do you have to document all individualized education program (IEP) discussions in the minutes? What if parents want to add something to the minutes? What if something is not included in the minutes?

There is no requirement to take minutes for the IEP meeting; in fact, minutes should not be taken. What is recommended is taking notes that document what happened during the meeting. Specifically, notes should document that the appropriate process was followed, including important actions such as:

• informing parents of their rights and offering to review these rights (also include their response)
• reviewing progress on goals set the prior year
• reviewing assessments, if applicable
• discussing present levels of academic achievement and functional performance.

The IEP notes are not intended to be a verbatim transcript of the meeting, but rather a summary of the actions held. Several important matters to cover in your notes are

• parent input and participation
• areas of consensus or disagreement
• the district's offer of a free appropriate public education (FAPE).

A good practice is to read the notes at the conclusion of the meeting to be sure they accurately reflect what happened and capture important professional practices you followed. If the parent(s) want to add something, or they disagree with the SLP, they can provide information in writing that can be attached to the IEP. If a parent points out an error, you should correct it. However, it is not appropriate to make other changes: The IEP is the district's document, so it should not be changed or given to the parent to complete.

What documentation is required when modifications to the IEP are needed?

There are several ways to make changes to the IEP.

• The entire IEP team can modify the plan at an IEP team meeting
• The parents and the school may agree not to convene an IEP Team meeting to make changes, and, instead, may develop a written document to amend or modify the IEP.

If changes are made to a child's IEP, the school must ensure that the IEP team and the parent(s) are informed of those changes. Districts have forms for this purpose. For IEP team meetings, the parent(s) and the school may agree to use alternative means of meeting participation, such as video conferences and conference calls. See IDEA Section 34 CFR 300.324(a)(4)(i). Although there are provisions in IDEA 2004 to allow changes to be made without a meeting, we recommend that you always contact a supervisor before doing this. Changes or alterations in IEP services without an IEP meeting can be held to be a violation of the child's FAPE and, hence, could have legal consequences. This can be the case even if the parent verbally agrees that a proposed change is acceptable and that a meeting is not necessary.

Meaningful parent involvement is key to successful IEP programming. Otherwise, parents may not feel confident that they understand, or have fully participated in, making the recommended changes. Scheduling meetings can be a challenge, but parents in particular can benefit from a team discussion of issues such as increasing services, changing service delivery models, discontinuing services, or behaviorally related problems. Respecting and following the process allows for documentation of rationale and input by all parties and helps avoid misunderstandings. Without this kind of documentation, a district may find it difficult to defend itself against potential parental challenges.

Can you hold an IEP meeting if parents do not attend/show?

Parents are required members of the IEP team. If a parent does not come to an IEP meeting, then the meeting should not be held. Each school district has procedures for parent notification and what to do if the parent does not come to the meeting. Typically, multiple attempts are made to contact the parent, and options are offered to find a mutually agreeable meeting time. Such efforts include phone calls during evening hours, registered or certified mail, and offers for video conferences or conference calls which are permissible alternate means of meeting participation.

If all such attempts have failed, it is wise to obtain a supervisor's approval before holding an IEP meeting without parents present. Also, in such cases, you should document in the IEP all attempts to contact the parent and should mail the IEP to the parent by certified or registered mail. For a comprehensive review of these requirements see IDEA Section 34 CFR 300.328.

Is there any flexibility in documenting how often services are provided (e.g., two times per week vs. contacts per month)?

In short, no. Services must be provided according to what is agreed to in the IEP. Using the ASHA Workload Analysis Approach for documenting services per month or per quarter allows for greater flexibility and is a highly desirable way to document services. Some districts accept minutes per reporting period or semester as an acceptable means of recording frequency and duration of services. The IEP could also indicate how the frequency and location of services may change depending on the child's needs and progress. Check with your state or district regarding their policies for reporting services.

What are the key components of a measurable IEP goal?

IEP goals should be derived from an area of need identified in an assessment or other method of determining present level of academic achievement or functional performance. Goals must be measurable and need to focus on what the student will do. The American Association of California School Administrators (ACSA, 2006) provides the following six questions to answer when writing IEP goals:

• Who...the student
• Does what...observable behavior
• When...by reporting date
• Given what...condition
• How much...mastery or criteria
• How will it be measured...performance data
• Keeping data, or a portfolio of the student's performance on goals, is recommended

Treatment Notes/Records

What constitutes an official school record? Does it include treatment notes, lesson plans, progress notes, notes to parents, personal notes, 504 accommodation plans?

School records generally fall into three categories (see Moore, 2010a, as cited in Moore, in press):

1. Mandatory permanent pupil records
• are required by state law
• usually include identifying information about the pupil, when the student attended schools in the district, and records of subjects taken, grades, immunization, and date of graduation or exit
2. Mandatory interim pupil records
• required by state law
• held for a stipulated period of time
• includes health information, special education information, language training records, progress reports, parental restrictions, parent/pupil challenges to records, parent authorizations/prohibitions for student participation in certain programs, results of standardized tests
3. Permitted pupil records
• Counselor/teacher rating scales, standardized tests older than 3 years, routine discipline, behavioral reports, discipline notices, and attendance records

Types of documentation and their status as records include the following:

• Treatment notes or progress notes and 504 accommodation plans are considered school records
• Lesson plans are not school records
• Notes taken as personal memory aids may be considered "sole possession" notes.
• Notes to parents and personal notes may not be considered school records, unless they are placed in the student's file. However, it is best to assume that any e-mail or document that includes a student's personally identifiable information will be considered a student record. See Letter to Otter [PDF] for more information.

Where should official records be kept?

School districts vary in terms of where pupil records are kept. The main goal is to restrict access to ensure confidentiality. Most school districts have a system whereby the files are kept in locked file cabinets with limited access. Often, lists with the names of those who can have access to the student records are posted on the file cabinets. Most special educators have locked file cabinets in their rooms, so that their teacher/specialist file can be kept secured.

How long do I need to keep student records?

State and district procedures vary on this, and it also depends on the type of student record.

• Mandatory student records, such as transcripts, may never be destroyed.
• Special education records must be kept for 3 years after the student separates from the district through graduation or aging-out
• However, if a student leaves the district due to relocation, then records are sent to the new district; the records must follow the student.
• In terms of teacher/SLP files, check with your local district administration about applicable procedures when a student is no longer on your caseload or at your school.

With regard to retaining documentation, please note the following:

• State Medicaid for school-based reimbursement may require a different length of time for records (documentation) to be kept. Please check with your district Medicaid Administrator to confirm the length-of-time requirement.
• Confidential records should be securely disposed of by shredding the documents rather than throwing them away.

What should be included in therapy notes?

The standard for therapy notes in schools is no different from that for any other work setting for SLPs or audiologists. Most important, notes should document service provided and student performance.

For billing purposes, you may want to review requirements for clinical therapy notes for Medicaid. The SOAP note format (Subjective/Objective/Assessment/Plan) is not always used in school settings, but is a good method to ensure your notes include all appropriate information (Moore, in press).

Remember that whether it is an auditor or an attorney who reviews your notes, what happened in the session should be clear. Consider whether another SLP could read the notes and accurately determine what to do next.

What should be included in an assessment report?

Assessment reports generally follow this standard format (see Moore, 2010a, 2010b, as cited in Moore, in press):

• reason for assessment
• background information
• assessments
  • standardized assessments or tests
  • observation in natural setting
  • non-standardized assessments or methods
  • activities within natural setting
• behaviors observed during assessment
• information on progress in academic or curricular areas
• information on classroom assessments and statewide assessments
• information from others (teacher, parent, aide, other team members)
• input from the student on his or her disabling condition, thoughts, desires, and wishes
• impressions
• summary/conclusions
• recommendations

Can parents insert other information into an assessment report?

An assessment report is the work of the assessor or assessment team. The parent cannot insert information into the assessment report. If the parent provides evidence of a factual error (e.g., misidentification of the city where the child was born), then the report should be corrected. However, if the parent disagrees with conclusions or interpretation, the parent can submit documentation for the file; the assessor does not need to change the report. School districts have processes and board policies for amending student records. Parents will need to be advised of these procedures if there is such an issue.

How should reports from other agencies be handled?

Reports from other agencies should be considered at an IEP meeting. The same is true for reports from other providers.

Electronic/Other Communication

Should e-mail communications be kept in the student file? Are they part of the "official" record? Is the same true of fax confirmations/text messages/postal receipts?

E-mail is considered part of the student record if it is placed in the student record. E-mail, text messages, and other electronic communications can be subpoenaed regardless of whether they are part of the student record. Fax confirmations and postal receipts would be considered appropriate to be included in the student file. All content with personally identifiable information (PII) is considered part of the student record, so if the student's name is in the e-mail, it is assumed to be part of FERPA. Be judicious with e-mail and limit information shared regarding students.

Should telephone conversations be documented? If so, in what form should phone conversations be documented?

Yes, phone conversations should be documented. Options for the form include

• tablets or paper files
• computer files
• recording files (e.g., generated by web conferencing program like GoToMeeting) that can be included in the student's electronic record or transcribed

Keep these tips in mind:

• For each record, include the time and date (including the year).
• For recorded conversations, make sure all participants are aware the conversation is being recorded. In many states, permission to record a conversation is legally required. If you are unsure about your state's stance, either obtain permission from all parties prior to recording or research the matter in advance of the call, conversation, or meeting.

Test Protocols

Where should test protocols be kept and for how long?

Test protocols are often kept in the teacher/specialist file or in the district's special education file. Consult your district's policies for how long and where protocols will be maintained.

Can test protocols be destroyed after the information is included in the diagnostic report/multidisciplinary team evaluation?

No, once the protocol has been completed, it becomes a student record and cannot be destroyed until the appropriate time, as prescribed by record destruction procedures.

Can parents see and have a copy of the test protocols?

Under FERPA, there is a difference between allowing access to records and providing copies. FERPA does not require that copies of documents be provided. Rather, FERPA establishes the right of parents "to inspect and review the education records of their children." The law requires schools establish procedures that enable parents to review their children's records within a reasonable time after a request is made. FERPA requires a copy be provided only where a parent would not otherwise be able to review the student's record (e.g., a parent is disabled and cannot travel to the school).

FERPA neither requires nor prohibits the sharing of test protocols. FERPA also does not define specifically what constitutes the official "student record." Those decisions are left to states and local agencies. However, any document that is considered a part of an official student record is then protected under FERPA.

Recent court cases support the fact that it is NOT a copyright violation to provide a copy of a protocol to a parent, because that situation does not infringe on proprietary business rights (i.e., one can assume the parent is not going to publish, or otherwise misuse the protocol). Check with your state or district regarding their policies.

Response to Intervention

How should we document RTI services?

Because there is wide variability in how RTI services are provided, the best rule of thumb is to document the same way you would for IDEA services.

Other

What kind of documentation is needed for home school students? What about for private school students?

Assuming that these students are special education students, the documentation requirements remain the same. Private school students may have a service plan, but the documentation requirements in terms of treatment are the same. States vary in their requirements, so check with your local district on these issues.