Five Common Documentation Questions—Answered If it’s not documented, it didn’t happen. How many times have you heard that? Long a concern for speech-language pathologists and audiologists, the paperwork burden in schools seems only to be growing along with the demands of due process and accountability (see table [PDF]). And with the increased paperwork comes ... Features
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Features  |   April 01, 2012
Five Common Documentation Questions—Answered
Author Notes
  • Barbara J. Moore, EdD, CCC-SLP, is director of Special Youth Services in the Anaheim (California) Union High School District, ASHA vice president for planning, and an affiliate of ASHA Special Interest Groups 1 (Language Learning and Education), 11 (Administration and Supervision), 16 (School-Based Issues), and 17 (Global Issues in Communication Sciences and Related Disorders). Contact her at moorebarb@att.net.
    Barbara J. Moore, EdD, CCC-SLP, is director of Special Youth Services in the Anaheim (California) Union High School District, ASHA vice president for planning, and an affiliate of ASHA Special Interest Groups 1 (Language Learning and Education), 11 (Administration and Supervision), 16 (School-Based Issues), and 17 (Global Issues in Communication Sciences and Related Disorders). Contact her at moorebarb@att.net.×
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School-Based Settings / Features
Features   |   April 01, 2012
Five Common Documentation Questions—Answered
The ASHA Leader, April 2012, Vol. 17, 22-24. doi:10.1044/leader.FTR3.17042012.22
The ASHA Leader, April 2012, Vol. 17, 22-24. doi:10.1044/leader.FTR3.17042012.22
If it’s not documented, it didn’t happen. How many times have you heard that?
Long a concern for speech-language pathologists and audiologists, the paperwork burden in schools seems only to be growing along with the demands of due process and accountability (see table [PDF]). And with the increased paperwork comes a slew of questions about the whats and hows of requirements and procedures.
We all know we should adhere to federal, state, and local policies and procedures. But try as we might, we often are confused about exactly what to do. To assist members, ASHA recently launched a documentation website, with detailed answers to frequently asked questions (FAQs) about documentation.
As one of those who helped compile the FAQs, I provide here some quick guidance on five of the most commonly asked questions.
Q: How do I make sure I’m prepared to handle due process proceedings, attorneys, and courts?
Imagine you have sworn to tell the truth, the whole truth, and nothing but the truth, and now must explain to a judge why you took the actions you did. Oh, and it’s been three years since you worked with the student. This situation shouldn’t pose a problem if you have practiced good habits of complete documentation.
Although you’ll have been prepared by the school district’s attorney, ultimately you’ll be directed to numerous documents that have been put into evidence. If they’re thorough, these documents will spur your memory, helping you to provide a clear rationale for what you did, no matter how long ago it was.
The good news is that recent court decisions show that when school personnel demonstrate that they are knowledgeable, follow procedures, and provide appropriate services, districts prevail. Treatment logs and data demonstrating progress, or lack thereof, is particularly critical in these cases, as are evaluation documents and reports indicating procedural compliance with Individualized Education Programs (IEPs).
In some cases, parents may bring in outside experts to challenge your work. Be prepared for judges and courts to look at both the substantive and procedural aspects of your case.
Q: What should I be sure to include in reports?
We all have been trained on report writing, but in schools, the speech and language assessment is part of a multidisciplinary team assessment, and needs to reflect other disciplines’ input. Both audiologists and SLPs in schools need to connect their assessment results to the student’s classroom functioning. One common report-writing error is to document results of standardized assessments without connecting the results to the student’s class performance or results of other assessors.
In addition, reports should always include:
  • Explanation of the student’s needs and justification of the need for services.

  • Pertinent background, discussion of assessment results, and explanation of the choice of assessment instruments.

  • Interviews with parents and teacher(s) regarding the student’s observable communicative behavior. Include assessment information on and discussion of other learning or behavioral needs, if applicable, especially if there is a difference between what the parents, teacher, and assessors report.

  • Documentation of classroom observations of the student that indicate how the communication behavior impedes the student’s learning progress.

Q: How do I avoid common missteps when writing IEPs?
Documentation errors happen when special educators—including SLPs and audiologists—document only assessment results or information from prior IEPs. Instead, you need to document specifics on how students’ present areas of need affect their ability to access the curriculum.
For example, instead of indicating, “Sam has a semantic deficit and an auditory processing disorder,” the IEP should say, “Sam’s vocabulary skill deficits affect his ability to read and comprehend at grade level.”
The IEP might then continue with something to the effect of: “Teacher assessments and classroom performance demonstrate difficulties in reading fluency. Sam’s verbal expression is adequate to answer questions in the classroom. However, word-finding problems are apparent during narrative tasks. General oral communication skills are adequate for daily functioning.”
In addition, the IEP needs to link explicitly the areas of assessment, identified areas of need (present performance), goals, and services. For example, based on the levels described above, there should be vocabulary and word-finding assessments, as well as a narrative assessment, to support the information. The next step, then, should be developing goals in these areas.
Also critical is the need for IEPs to focus on standards and be curriculum-based, per the Individuals With Disabilities Education Improvement Act (IDEA) of 2004. Although online IEP programs typically provide the format for writing goals, service providers must still determine goal content. Goals must determine what the student should do and must be measurable, so setting appropriate criteria is key. Use the goal-guidance section of the ASHA website to avoid common goal-related errors, such as:
  • Goals are vague or general, and thus unmeasureable.

  • Required progress reports are not completed and documented in the central file.

  • Tracking or evidence of the student’s progress toward the goals is not documented.

Q: What should I know about requests for records, including protocols?
One sign that a legal challenge could be in the offing is a formal written request to the school for all files on a given student, including the special education file, the cumulative file, the health file, the discipline file, the teacher file, and treatment notes. (A parent’s request for a single copy of an IEP or assessment report is not a cause for alarm.) Your school district likely handles such requests via a formal procedure and legally will need to respond within a set timeline, generally five business days.
The Federal Educational Rights and Privacy Act (FERPA) authorizes parents to obtain and review student records. School-based personnel are sometimes confused about whether or not assessment protocols are to be included when copying records for parents. The confusion arises from copyright laws pertaining to test protocols. Copying blank protocols for the purpose of using these protocols during assessments, in lieu of purchasing new protocols, is a copyright violation. However, once a test protocol has been completed by an assessor, the protocol becomes a student record. As such, when a parent makes a request for copies of records, the completed protocol is included.
Q: What should I know about informal and online communication?
All staff who work in schools should be cautious about what they write in e-mails because of student confidentiality concerns. E-mails are not necessarily considered a student record, unless printed and put into a teacher or special education file. However, attorneys may subpoena e-mails as part of legal discovery procedures. The consideration of how e-mails are treated in terms of student records is an evolving area of practice.
The same caution is necessary for personal files or records. Do not assume that your personal notes about a case are immune to discovery, or that they can’t be subpoenaed—they can. It is perfectly acceptable to maintain notes on a student to aid your memory, but be prepared for these files to be deemed a part of the student record. The best advice here is to be careful. Be objective and avoid labels or personal characterizations.
Any reference to students and situations in schools should be avoided in social media. Although challenging situations at work may seem like something to Tweet or post, they are not. Such actions can lead to serious personnel problems for the employee.
Documentation in the school setting acts as the evidence that we did what we were supposed to do. First and foremost, SLPs and audiologists need to remember that the legal requirements in special education are set forth to ensure protections for students. Complete and thorough documentation builds the framework for the programs and services a student is to receive. Documentation lays out a clear plan and shows evidence of connection between assessment, goals, and services. When there are new areas of concern, documentation shows that we addressed them, even if the concerns arise years later.
The five areas of documentation concerns discussed here are common in school settings. It is best to first direct documentation questions to local district administrators or legal counsel. Attentiveness to documentation issues is important in all work settings, but especially so in schools—so practice good documentation habits.
Resources

Moore, B. J. (2010). Documentation for SLPs and Audiologists in Schools. (Audio Program). Rockville, MD: ASHA.

Moore, B. (in press). Documentation issues in speech-language pathology and audiology. In R. Lubinski & M. Hudson (Eds.), Professional Issues In Speech-Language Pathology and Audiology (4th Ed.) Clifton Park, NY: Cengage/Delmar Publishers.

Moore, B. (2010, October). If it’s not documented, it didn’t happen. ASHA Special Interest Division 11 (Administration and Supervision) Perspectives, 20, 106–112.

Moore, B., & Montgomery, J. (2008). Making a difference for America’s children: Speech-language pathologists in public schools (2nd Ed). Austin, TX: PRO-ED.

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April 2012
Volume 17, Issue 4