Documentation Guidelines for Employees

PLEASE NOTE: Documentation should be typed on letterhead and signed by the treating provider. Prescription pad notes are not acceptable, and will only be used on a temporarily basis (if they can be read) while sufficient documentation is being produced.

Employees requesting accommodations and/or services under the Americans with Disabilities Act (ADA) must provide documentation of the existence of a disability that substantially limits a major life activity.  In order to accurately determine appropriate accommodations, documentation should be current. We request that it be dated within the last year for medical or psychological conditions and updates may be needed on a yearly basis if a condition is not static or chronic.  Evaluations for ADD and LD should reflect the employee’s current functioning.  In all cases, the documentation should be appropriate to the anticipated setting.

Documentation should include though not necessarily be limited to the following:

  • The credentials of the evaluator(s).

Be provided by a licensed or otherwise properly credentialed professional who has undergone appropriate training, has relevant experience, and has no personal relationship with the client.

  • A diagnostic statement identifying the disability.

Include a clear diagnostic statement to describe how the condition was diagnosed, provide information on the functional impact, and detail the typical progression or prognosis of the condition.  Diagnosis codes are helpful but not required.

  • A description of the diagnostic methodology used.

Describe the diagnostic criteria, evaluation methods, procedures, tests, and dates of administration, along with a clinical narrative, observation, and specific results.  Where appropriate to the nature of the disability, having both summary data and specific test scores is expected.

* (Please refer to the list of appropriate diagnostic tools for ADHD and LD at the end of this document.)

  • A description of the current functional limitations.

Describe how the disabling condition(s) currently impacts the individual for the purpose of establishing a disability and identifying possible accommodations.  Documentation should be thorough enough to demonstrate whether and how a major life activity is substantially limited by providing a clear sense of the severity, frequency and pervasiveness of the condition.

  • A description of the expected progression or stability of the disability.  

Provide information on expected changes in the functional impact of the disability over time and context.  Descriptions of the cyclical or episodic nature of the disability and known or suspected environmental triggers to episodes provide opportunities to anticipate and plan for varying functional impacts.

  • A description of current and/or past accommodations, services, and/or medications.

Include both current and past medications, auxiliary aids, assistive devices, support services, and accommodations, including their effectiveness in alleviating functional impacts of the disability.

  •  Recommendations for accommodations.

Recommend accommodations, adaptive devices, assistive services, compensatory strategies, and/or collateral support as appropriate to the functional limitations.  There may be some limits to what can reasonably be provided, but we would like to know about anything your provider feels might be helpful.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking you not to provide any genetic information when responding to this request for medical information. ‘Genetic information’, as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or a family member receiving assistive reproductive services.

*When documenting ADHD, the following instruments are recommended:

  • Interview with partner (or another adult with integrity of knowledge of patient) reflecting concerns, history of each concern, review of developmental domains (motor, sensory, language, intellectual, self-help, academic, emotional, and social), review of family relationships, review of parent management tactics, review of family social circumstances, developmental/medical history, prior evaluations, information regarding onset, longevity, severity of symptoms and treatment.
  • Behavior rating scales from parents (or another adult with integrity of knowledge of patient) such as ADHD Rating Scale (DSM-IV).
  • Behavior ratings scales for the patient to include self-rating on broad band measures, such as the Child Behavior Checklist (Adult Self) and/or Wender Utah Rating Scale (WURS) and narrow band measures, such as ADHD (DSM-IV) for current functioning and recall of childhood functioning.
  • Structured psychiatric interview along with objective measures (SCL-90-R, MMPI-II) to rule out schizophrenia, major disorders, borderline personality disorders, pervasive development disorders (autism, Asperger's) and mental retardation.
  • Documentation of impairment where available (school, mental health, pediatric, other medical, work and driving records).

 We strongly recommend that in addition to the instruments listed above, the following assessments also be conducted in order to identify  possible co-existing learning issues and to assist in determining the most appropriate accommodations.

  *Documentation of Learning Disorders should include assessments of:

Cognitive functioning - A complete battery of tests, appropriate for an adult should be conducted, with all subtest and standard scores reported. One of the following would be required: Wechsler Adult Intelligence Scale (WAIS-III), Woodcock-Johnson Psycho-educational Battery IV: Tests of Cognitive Ability, or the Kaufman Adolescent and Adult Intelligence Test.

Achievement - A complete battery relevant to area(s) of suspected disability(s), often to include  a reading assessment, with all subtest and standard scores  reported. Examples of commonly used tools are: Woodcock-Johnson Psycho-educational Battery IV: Tests of Achievement, Stanford Test of Academic Skills (TASK), Wechsler Individual Achievement Test (WIAT),  and Nelson-Denny Reading Skills Test.

Information Processing - An examination of processing strengths and weaknesses to include areas such as short and long term memory, processing speed, meta cognition, etc. gathered from the comprehensive assessment, diagnostic interview, and examiner's observations of test behavior.