Documentation Guidelines

These guidelines apply to medical disabilities (including mobility, chronic health, manual, and sensory disabilities) and conditions resulting from temporary illnesses or injuries.

Documentation should:

• Be provided by a clinician qualified in the relevant specialty and not related to the student.
• Be written on professional letterhead, be current (typically within the last 3 months), and include the date of the last appointment.
• Provide a clear diagnosis.
• Include relevant medical and treatment history.
• Describe current medications, treatments, assistive devices/technologies, and their effectiveness, including any side effects that affect functioning.
• Describe functional limitations in a graduate educational setting and any limitations on allowable activities, if relevant.
• Clearly explain the connection between the disability and the requested accommodations.

Evaluations must be conducted by a qualified professional who:

• Has extensive training and experience with adolescent and adult LD populations.
• Has expertise working with culturally and linguistically diverse populations.
• Is not a family member of the student.

Documentation must generally be within the past 3–5 years and should include:

• Summary of a diagnostic/clinical interview.
• Assessment of major domains of cognitive and academic functioning.
• List of tests administered, with all standard scores.
• Expert interpretation of results.
• Clear diagnosis and statement of disability.
• Discussion of functional limitations and academic functioning levels.
• Recommendations for accommodations.

The diagnostic/clinical interview summary should address:

• Presenting concerns.
• Developmental history of language, speech, and motor skills.
• Relevant medical history, including exclusion of medical explanations.
• Academic history, including uneven achievement and prior standardized testing with or without accommodations.
• Reports of uneven classroom performance/behavior.
• Relevant family, psychosocial, and employment history.
• Consideration of dual diagnoses or co‑existing conditions and any history of medication that may affect learning.
• History of auxiliary aids, services, and accommodations.
• Exploration of alternative explanations that may mimic a learning disability.

Neuropsychological or psycho‑educational assessment must provide clear evidence for or against an LD diagnosis and include:

• A comprehensive, individualized, standardized, adult‑normed battery.
• Objective evidence of substantial limitation to learning, based on a pattern of performance.
• Description of any factors that may affect test validity (e.g., medication status).

At minimum, the report must address:

• Aptitude/cognitive ability: full intellectual assessment with all subtests and standard scores.
• Academic achievement: comprehensive battery assessing reading, writing, verbal expression, math, and timed performance (fluency).
• Cognitive and information processing: memory, processing speed, attention, executive functioning, motor functioning, sensory‑perceptual functioning, visual acuity, and any need for corrective lenses.
• Informal measures: classroom tests, informal assessments, and observations integrated with formal testing.
• Error analysis: narrative description and interpretation of significant error patterns.
• Behavioral observations: including anxiety, fatigue, or motivational issues.

The documentation must:

• Provide a specific LD diagnosis using DSM‑IV and/or ICD‑10 nomenclature, describing the nature and severity of the disability.
• Explain the impact on major life activities, especially learning.

A clinically interpretive summary should:

• Rule out alternative explanations such as limited educational opportunities, poor study skills, emotional or attentional problems, or cultural/language factors.
• Explain how cognitive, achievement, and processing patterns support the LD diagnosis.
• Demonstrate substantial limitation to learning and its impact in the requested context.
• Justify each requested accommodation and link it to the documented functional limitations.
• Clearly identify recommended accommodations; the HMS Director of Disability Services may request clarification or additional information and will make final determinations.
• Address any absence of prior accommodations and explain why they are needed now, if applicable.
• Incorporate or summarize additional documentation that corroborates functional limitations and supports the request.

HMS does not release documentation without the student’s informed consent or as required by law.

Evaluations must be conducted by a qualified professional who:

• Has training in the differential diagnosis of ADHD.
• Has direct experience with adolescent or adult ADHD populations.
• Is not a family member of the student.

Documentation should typically be within the past 3–5 years and include:

• A comprehensive assessment with diagnostic interview, neuropsychological and/or psycho‑educational testing, and (when available) third‑party reports.

The diagnostic interview should cover:

• History of attentional symptoms and evidence of persistent impairment over time.
• Developmental history.
• Family history of ADHD or related difficulties.
• Relevant medical and medication history, including exclusion of medical causes.
• Psychosocial history and prior interventions.
• Detailed academic history across educational levels.
• Review of prior psycho‑educational testing.
• Relevant employment history.
• Description of current functional limitations in educational settings.
• History of therapy.

Assessment must:

• Establish an ADHD diagnosis and demonstrate its current impact, especially on test‑taking under time pressure and academic functioning.
• Include test data (e.g., cognitive, memory, attention, continuous performance tests, checklists, clinical observations) that logically support a substantial limitation to learning.

Documentation must include:

• A specific ADHD diagnosis based on DSM‑IV criteria.

The interpretive summary should:

• Rule out alternative explanations (e.g., psychological, medical, or non‑cognitive factors).
• Explain how symptom patterns across settings and over time support the diagnosis.
• Indicate whether evaluation occurred on or off medication and the response to treatment.
• Describe the degree of functional limitation in academic settings.
• Justify requested accommodations and explain how they address ADHD‑related impairments.

Documentation Guidelines for Psychological Disabilities

Evaluations must be conducted by a qualified professional who:

• Has training and experience in the differential diagnosis of psychiatric disorders.
• Holds appropriate licensure/certification.
• Is not a family member of the student.

Because psychiatric conditions can change over time, documentation must reflect the current level of functioning and need for accommodations.

• If the diagnostic report is more than six months old, students must submit an updated letter from a qualified professional describing current functioning over the past six months, any changes in condition or treatment, and a rationale for requested accommodations.

A comprehensive assessment should include:

• History of presenting symptoms, including duration and severity.
• Relevant developmental, historical, and family information.
• Relevant medical and medication history, including current regimen, side effects (if applicable), and treatment response.
• Description of current functional limitations across settings (e.g., academic, residential, work).
• For residential settings: description of behaviors that may affect dormitory life and the stability or progression of symptoms.
• For academic settings: expected course of the condition over time and impact on performance.
• Information on type, duration, and consistency of therapeutic interventions.

Documentation must:

• Provide a specific diagnosis using DSM‑V or ICD‑10 criteria, including numerical and nominal codes.
• Cite objective measures used to substantiate the diagnosis, when applicable.
• Rule out alternative explanations (e.g., neurological or medical conditions, substance use, educational or cultural factors).

The evaluation must also:

• Explain the current impact of the condition on major life activities.
• Clearly link requested accommodations to the functional limitations relevant to academic and/or residential settings.
• Recognize that a diagnosis alone does not guarantee particular accommodations.

For students with multiple diagnoses, documentation should follow all relevant HMS guidelines and may support a broader range of accommodations than typically associated with a single diagnosis