Documentation in Schools

Documentation is a primary method of communication between clinicians (i.e., audiologists and speech-language pathologists), payers (i.e., Medicaid), administrators, and other stakeholders involved in a student’s education and social–emotional needs. Complete documentation is a requirement to ensure compliance with provision of a student’s individualized education program (IEP) and 504 plan.

Documentation formats vary among education systems, and ASHA does not recommend or suggest a single format or timeline. State or federal agencies governing schools, Medicaid reimbursement policies, or audiology and speech-language pathology regulations may have specific requirements for documentation. Any documentation must meet state and federal agency requirements. School districts or payers may have additional requirements. See ASHA State-by-State for more information.

Thorough and consistent documentation is critical for making appropriate decisions for students. Unclear, vague, or missing documentation can result in compliance violations, ethical charges, the inability to defend decisions in a due process hearing, difficulty following the clinical judgment underlying the diagnosis and treatment of the underlying disability, and denials for Medicaid reimbursement. Thorough documentation may help protect school districts and service providers in mediation and due process situations by demonstrating adherence to legal requirements and evidence-based practice of the field. Any official student record can be reviewed and discussed for legal purposes, such as due process complaints and hearing office determinations. It is, therefore, important that documentation aligns with the prescribed services on the IEP (dosage) and complies (i.e., addresses identified goals) with the IEP. Documentation must connect identified student needs based on diagnosis, results of assessment in all areas of suspected disability, eligibility determination, development of goals, and recommendation for treatment services, including the service delivery model.

Translation of documents for multilingual students and parents should be provided as necessary, including, but not limited to, IEP documentation. This is a requirement of the Individuals With Disabilities Education Improvement Act of 2004, but clinicians should follow local (e.g., school district) policies and processes for these requests (U.S. Department of Justice & U.S. Department of Education, n.d.). Clinicians should be careful to use the appropriate pronouns in documentation (e.g., “they” as opposed to “he” or “she”) or to use the child’s first name instead.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.

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