Guidelines for Documentation of a Psychiatric Disability

It is important to note that "psychiatric disabilities" is a generic term used to refer to a variety of conditions involving psychological, emotional, and behavioral disorders and syndromes. The terms psychological disabilities and psychiatric disabilities are used interchangeably in this document. The official source designed to outline the criteria used in making diagnoses are the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV-TR).

Introduction
Students requesting accommodations or services because of a psychiatric disability at the University of Kansas Medical Center are required to submit documentation to determine eligibility in accordance with the Federal Rehabilitation Act of 1973, and/or the Americans with Disabilities Act of 1990 (ADA) and/or the Americans with Disabilities Act Amendments Act (ADAAA). A diagnosis of a disorder/condition/syndrome in and of itself does not automatically qualify an individual for accommodations under the law. For individuals previously diagnosed who have not continuously received medical or educational support, a comprehensive evaluation may be necessary to determine whether accommodations are appropriate. To establish that an individual is covered under the Rehabilitation Act, and/or the ADA and/or the ADAAA, the documentation must indicate that the condition substantially limits some major life activity and/or major bodily function.

The following guidelines are provided in the interest of assuring that documentation of a psychiatric disability is complete and supports the request for accommodations. The University of Kansas Medical Center will determine eligibility and appropriate accommodations, case-by-case, based on the quality, recency and completeness of the documentation submitted. The following guidelines provide students, schools and qualified professionals with a common understanding of the components of documentation that are necessary to validate a diagnosis of a psychiatric disability, the impact on the individual's educational or job performance, and the need for academic or job accommodations for the purpose of the ADA, the ADAAA or the Rehabilitation Act.

Terms

Psychiatric disabilities: Comprise a range of conditions characterized by emotional, cognitive, and/or behavioral dysfunction. A diagnosis of a disorder does not, in and of itself, meet the definition of a disability necessitating reasonable accommodations under the ADA, the ADAAA or the Rehabilitation Act.

Major life activity: Examples of major life activities include walking, sitting, standing, seeing, hearing, speaking, breathing, learning, working, caring for oneself, concentrating, thinking and other similar activities.

Major bodily functions: Examples of major bodily functions include the operation of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine and reproductive functions.

Functional limitation: A substantial impairment in the individual's ability to function in the condition, manner, or duration of a required major life activity.


Documentation Requirements

A Qualified Professional Must Conduct the Evaluation
The assessment must be administered by a trained, qualified, and licensed professional, who has had direct experience with adults with psychiatric disorders. A qualified professional may include but is not limited to a medical doctor, psychologist, or student clinician who is being supervised by a professional. The evaluator's name, title and professional credentials and affiliation should be provided. The professional completing the evaluation should not be a family member. All reports should be on letterhead, typed, dated, signed, and otherwise legible.

Documentation Must Be Current
Reasonable accommodations are based on the current (i.e. within the last six months) impact of the disability on academic or job performance. A diagnostic evaluation should be relevant to the individual's environment and show the individual's current level of functioning. If documentation does not address the individual's current level of functioning, a re-evaluation may be required.

Documentation Must Include a Specific Diagnosis
The report must be comprehensive and include a specific diagnosis based on the DSM-
IV-TR diagnostic criteria. It is recommended that the clinician report the diagnostic criteria used to support the diagnosis. The diagnostician should use direct language in the diagnosis, avoiding the use of terms such as "suggests" "appears" or "is indicative of".

Co-existing Conditions
The diagnostic assessment should examine the possibility of co-existing conditions including medical disorders and learning disabilities.

Documentation Must Be Comprehensive
Documentation should be based on a comprehensive diagnostic/clinical evaluation that includes the following:
1. History of presenting symptoms
2. Duration and severity of the disorder
3. Relevant developmental, historical, and familial data
4. Procedures used to diagnosis the disorder (include a list of all instruments used in the assessment and test scores as applicable)
5. A description of current functional limitations in the academic or job environment as well as across other settings
6. Relevant information regarding medications, the individual's history of compliance with medication and the anticipated impact on the individual in an academic or job environment
7. Relevant information regarding current treatment

Documentation Must Include Relevant Testing Information

Psycho-educational assessments are important in determining the current impact of the disorder on the individual's ability to function in an academic or employment setting. The report must include objective data, which might include, but not be limited to psychological assessments, educational assessments, rating scales, memory function tests, attention or tracking tests, or continuous performance tests. A score report page(s), which presents the test, sub test, standard scores, and percentiles, should accompany the report.

Current Plan for Treatment and Effects of Medication
The current plans for treatment, including the use of medications, should be summarized. Whether or not the individual was evaluated while on medication and whether the use of medications mitigates the impact of the disorder on the individual's ability to function in an academic or employment setting should be indicated.

Recommendations for Accommodations
A diagnostic report should include specific recommendations for accommodation(s). A prior history of an accommodation, without a demonstration of a current need, does not in and of itself warrant the provision of a similar accommodation. Each accommodation recommended by an evaluator should include a rationale. The evaluation should support the recommendations with specific test results or clinical observations. If an accommodation is not clearly identified in the diagnostic report, the University of Kansas Medical Center will seek clarification and, if necessary, more information. Whether or not recommendations are provided, the University of Kansas Medical Center will make the final determination as to what accommodations, if any, are appropriate, reasonable and warranted. The University of Kansas Medical Center reserves the right to request reassessment when questions regarding previous assessment or previous service provision arise. Depending on accommodations recommended, additional psycho-educational, neuropsychological or behavioral assessments may be necessary.


Revised: June, 2013

Last modified: Nov 19, 2013
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