Seven Essential Elements of Quality Disability Documentation
A description of the diagnostic methodology used
Quality documentation includes a description of the diagnostic criteria, evaluation methods, procedures, tests and dates of administration, as well as a clinical narrative, observation, and specific results. Where appropriate to the nature of the disability, having both summary data and specific test scores (with the norming population identified) within the report is recommended. Diagnostic methods that are congruent with the particular disability and current professional practices in the field are recommended. Methods may include formal instruments, medical examinations, structured interview protocols, performance observations and unstructured interviews. If results from informal, non-standardized or less common methods of evaluation are reported, an explanation of their role and significance in the diagnostic process will strengthen their value in providing useful information.