Documentation Doozies - California Speech Language and Hearing

Documentation Doozies:
Addressing Common Concerns in
School Settings
Barbara J. Moore, Ed.D., CCC-S
Director, Special Education, San Marcos USD
ASHA Vice President, Planning, 2011 - 2013
Barbara J. Moore
I do have publications on issues related to school
services, for which I do receive a royalty, and that may
discuss some of the issues reviewed in this presentation.
Some of the articles and information I have produced on
the topic of documentation were commissioned for a
fee; however, I receive no additional compensation for
those publications. I am receiving an honorarium for this
• Documentation Basics for School Settings
• 5 Documentation Doozies:
1. Due Process, Attorneys and Courts
2. Reports
3. Present Levels of Performance, Goals, Service
4. Request for Records, including protocols
5. Email and Personal Records
• Q&A
Why is this such a Hot Topic???
Because it’s CONFUSING!
• CONFUSION: Overwhelming mountain of
paperwork and variations in expectations for
• CONFUSION: Difference between what’s
documented and what’s done
• THREATS of due process
• High levels of professionalism in our field
• High level of expectation of our position
• More……..??????
Purpose of Documentation
• Through documentation we:
– Prove compliance
– Design plans
– Present rationale
– Justify recommendations
– Submit financial remuneration requests
(Moore, 2012)
ASHA Code of Ethics (2010)
Principle I, Rule M
• “Individuals shall adequately maintain and
appropriately secure records of professional
services rendered, research and scholarly
activities conducted, and products dispensed,
and they shall allow access to these records
only when authorized or when required by
law”(p. 2)
General Principles of Documentation
• Requirements for documentation set forth by
laws and regulations, as well as by the
professional expectations of our field
• Hint: use formal writing style, conventions of
formal written language, abbreviations as
• Documentation:
– Drives the action of the reader
– Reflects on the writer (you) and your program
(Moore, 2012)
• “If the record is not clear, concise, and
comprehensive, then the therapeutic process
is at risk” Hapner, 2008, p. 33
Levels of Laws and Regulations
• Federal
– Public Law (IDEA 2004)
– Code of Federal Regulations
• State
– State Law
– Education Code
• District
– School Board Policy
– Administrative Regulations
The BIG Laws!
• Compass for Protecting Individual Rights
– Rehabilitation Act of 1973/504
Focus on IDEA
• Pre-referral
– Didn’t used to worry about
this before IDEA 2004 and the
advent of RTI
– However, it’s always been
required to demonstrate that
general education cannot
meet the needs of a referred
– Now we are more systematic
– Now, SLPs are involved in the
pre-referral interventions
IDEA Eligible
– Clearer in terms of the expectations,
especially as it relates to timelines,
areas of the IEP, etc.
– BUT still many variations in WHAT is
put into and onto IEPs and reports
– What about other agreements, etc.
– Blending of general education
requirements into IDEA is
– Multi-disciplinary team develops IEP
and sometimes there is CONFUSION,
or a different style
– Even when we know what to do,
sometimes it’s hard to get it done!
• Electronic IEPs help in terms of completing the
requirements of IDEA
• Documentation should “thread the needle” –
tell the story of the student’s path
• Expectation in all settings; not just schools.
KEY: Documenting process
KEY: Documenting rationale
KEY: Documenting who is doing what and why
KEY: Documenting parental input into the IEP
KEY: Documentation consistency in your
• KEY: Documentation terminology (e.g. using
appropriate terminology)
• KEY: Doing what is documented!
Substantive vs. Procedural Violations
• Substantive Violations
– Denial of FAPE
– Failure to Assess
– Based on what you have done, has the student received
educational benefit?
– Have we failed to do something that we should have done?
• Procedural Violations
– Failure to comply with IDEA-mandated procedures
• Timelines, notice, meeting, documentation, etc.
– Does procedural violation rise to the level of a denial of FAPE
to the student, or impede the parents’ right to meaningfully
participate in the IEP process?
• Think about what the process of due process
is about. Can you provide documentation to
prove the following?
– > Can you show that you have provided a FAPE?
– > Can you show that the way you handled the
case was consistent with legal requirements?
– > Can you show that the way you handled the
case was consistent with standards of the field?
– > Can you show that you have the credentials to
do what you do?
• Process for Due Process: A Quick Review
– Filing
– Resolution Session, Mediation, Hearing
• Office of Administrative Hearing (OAH)
• What are they really looking for?
– Sample Cases
Documentation Doozie #2:
• S/L and audiology reports done as part of a
Multi-disciplinary assessment. Need to
connect to other disciplines.
only standardized testing results; Failure to
connect to classroom performance or results
of other assessors
Assessment and Evaluation Reports
• Be sure your report includes:
– pertinent background, discussion of assessment results,
and explanation of choice of assessment instruments
– documentation on suspected areas of need/ explanation
of student needs
– justification for needed services
– connection to other reports/assessments
– information on interviews with parents and teachers
Report should be written in a professional manner, using
professional terminology, but written so parents understand.
Assessment and Evaluation Reports
• Be sure your report:
documents suspected areas of need
connects to other reports
documents current areas of concern
is written in a professional manner, using professional
• Remember, your report reflects on both you and
your employer
• Consider what it would be like to have to testify
and defend your report—can it stand on its own?
Assessment Report Format
• Reason for Assessment
• Background Information
• Assessment/Testing:
– Standardized assessments or
– Observation in natural setting
– Non-standardized assessment
or methods
– Activities within natural
• Behaviors observed during
• Information on progress in
academic or curricular areas
• Information on classroom
assessments and statewide
• Information from others
(parents, teachers, aide,
other MDAT members)
• Input from the student
• Impressions
• Summary/Conclusions
• Recommendations
Assessment and Evaluation Reports
• Remember, your report reflects on both you
and your employer
• Consider what it would be like to have to
testify and defend your report—can it stand
on its own?
Documentation Doozie #3:
Present Levels of Performance, Goals, Service Delivery
IEP Contents:
Practice Pointer
• The IEP document should be comprehensive
enough that if the student moved to a new
district, the receiving school could implement
the IEP based on the document itself.
IEP Development:
Present Levels Information for the IEP
Information available from Student Data System
– CELDT (including language classification)
Information available from Student Data System
– Grades
– Discipline
– Health/attendance
Information available from teachers
– Benchmark testing
– Work samples
Input from parents and the student on concerns, desires, issues
Information from other related services providers (e.g., behavior specialist,
counseling, APE, etc.)
IEP Requirements
PRACTICE POINTER for the Present Levels
• Leave no section blank on the present levels
page. If the student is performing within
normal limits (WNL) or at grade level, note it!
• Make statements in positive language.
IEP Contents: Reporting Progress
• A description of the manner in which the
progress of the pupil toward meeting the annual
goals will be measured, and when periodic
reports on the progress the pupil is making
toward meeting the annual goals (e.g., through
the use of quarterly or other periodic reports,
concurrent with the issuance of report cards) will
be provided.
• MUST report to parents on a periodic basis on
progress toward goals!!
Student Progress
• Failure to make progress can be seen as a denial
of FAPE.
• Be sure to meet and account for any lack of
student progress.
• If a student is not making progress, then need to
reconvene an IEP meeting and discuss.
• If the student makes progress, document what
that means for the IEP (i.e., changing a goal or
service; dropping a goal or service).
• Don’t let student progress go undocumented–
one way or another!
Therapy Notes
• Therapy notes are an educational record
• Notes should document compliance with the
student’s IEP goals and service
• Expect that these notes will be requested
• Be objective in your documentation
• Be complete and concise, but it is not necessary
to be lengthy
• The old SOAP format is a good guide
• Be sure to date and initial the notes
Progress Notes: SOAP
• Subjective
– write your opinion regarding relevant client behavior or status in
a brief statement
• Objective
– record data collected for each task during the therapy session
• Assessment
– interpret data for current session and compare to client’s
previous level of performance
• Plan
– identify proposed therapy targets for the next session
Re-evaluation Reviews
• Need to re-establish if the student meets eligibility criteria and requires
special education and related services
• Review of student’s progress over the past three years
• Current review and documentation of student need
• All IEP team members must complete a report—this report can be
• Standardized measures may be used if needed, but are not required if the
team is completing an alternate or dynamic assessment
• MUST have documentation of student’s areas of need, including all goal
areas, and current functioning/progress
• Additionally required: all documentation necessary for the Annual (see
next slide!)
Documentation: Annual Review
• What’s required: Documentation
on ALL AREAS of NEED (e.g.,
– Work samples
– Portfolio of student progress
– Student data information
– Reports from classroom teachers
– Description of how special
education is assisting the student
Documentation: Annual Review
• What’s required: Documentation on ALL
AREAS of NEED (e.g., goals)
– Practice Hint: if the student is not demonstrating
an area of need in one of the sections indicated
on the IEP, you need to document that too! Make
statements about the student’s grade or ageappropriate functioning if this is the situation.
Leave no space blank!
IEP Development:
Goals and Benchmarks
• Areas of need are identified through assessment for
• Must be a goal for each identified area of need
• Document if student is no longer demonstrating an area of
• Can’t have a service without a goal
• Benchmarking (not a federal requirement; local policy)
• MUST report to parents on progress toward goals (i.e., the
benchmark) for each reporting period (federal requirement)
and review at IEPs (Note: be sure this gets documented for
the permanent record)
• Academic Goals MUST be standards-based
IEP Development:
Goal Information
• Provide meaningful interpretation of data
– build a bridge between the student’s performance
(i.e., the data, student classroom performance,
student grades, observational information, input from
other teachers and specialists) and the goals
• Need to compare to previous year’s goals and
progress reports, and report on this
• The record needs to reflect that goals and
progress have been reported to the parents at
required intervals
Goals Format
Does What:
Given what:
How much:
How will it be measured:
the student
observable behavior
by reporting date
mastery or criteria
performance data
Need to be standards-based
Need to be connected to the curriculum
Need to be measurable
OK to piggy-back on classroom goals
May have benchmarks – what’s your local
• Progress must be reported to parents on a
regular basis – same as gen ed. teachers reports
• Electronic systems often have drop-down menus
Speech and Language Goals
• IEP Guidance
– Consensus Points on Language Goals, Minneapolis
Public Schools (F. Cirrin)
– Writing Measurable Goals and Objectives (B. Conrad)
IEP meeting notes
Failure to Follow the Process will
Lead to Trouble
Service Delivery
• Service delivery models should be based on EBP
of the field
• Be sure that the recommendation is based on the
student need, and not the SLP convenience
• Consider current trends for intensity
• See work of Gillam & Gillam re narrative
development, esp. as it relates to groups
• Need to be able to connect rationale for service
delivery model
Documentation Doozie #4:
Requests for Records, including Protocols
Family Educational Rights and Privacy Act
• Three areas covered:
– access to their education
– an opportunity to seek to have
the records amended
– some control over disclosure of
information from the records
Record Retention Requirements
• Mandatory Permanent Pupil Records:
– Required by state law, which usually includes identifying information
about the pupil, when the student attended the schools in the district,
and records of subjects taken, grades, immunization and date of
graduation or exit.
• Mandatory Interim Pupil Records:
– Held for a stipulated period of time, including health information, special
education information, language training records, progress reports,
parental restrictions, parent/pupil challenges to records, parent
authorizations/prohibitions for student participation in certain programs,
results of standardized tests .
• Permitted Pupil Records:
– Counselor/teacher rating scales; standardized tests older than 3 years;
routine discipline; behavioral reports; discipline notices; attendance
Parent Requests for Records
• You know they have
the right!
• Be careful about what’s
in the file!
These are part of the student records
Are Permitted Student Records
Can be requested
Be sure to copy all pages, including the blank
• HINT: When they ask for copies of the
protocols, they are going to check your
Documentation Doozie #5:
Email, Social Media and Personal Records
• Is subject to subpoena
• Be very, very careful!
• If you don’t want the
child’s parent, your boss,
your mother, or a judge
reading it—then don’t
send it!
Social Media
• Hot, Hot, Hot Issue in Schools!!!
• Generally have to sign a use agreement in the
• Facebook, Twitter, etc. --- it’s exploding!
• Avoid any reference to students or situations in
these formats…. They can be tracked!
• Can lead to personnel problems if used
Personal Notes
• I say, “There’s no such thing!”
• Here’s what the law says, according to Shorter
▫ Education records does not include records of instructional,
supervisory, and administrative personnel and ancillary
educational personnel that are kept in the sole possession
of the maker of the record, and are not accessible or
revealed to any other person except a temporary
substitute. Keep in mind, however, that once a personal
note is shared, it becomes an “education record” (p. 21).
Creating Legally Defensible
• Make sure the record can stand on its own
• Can you “thread the needle” through the
documents, and tie everything together?
• In due process hearings, when parents’
testimony, or their witness testimony, contradicts
district, credence seems to be given to any
documentation the district has to support their
contention that “something took place” (i.e., logs,
postal receipts, fax confirmations, etc.).
One more thought….
• Don’t forget the importance of maintaining
good relationships with parents.
• BUT don’t think this will prevent them from
challenging what you do or what you’ve done!
Record Keeping and Documentation
• Yes, it’s true: if it’s not documented, it didn’t
• Get yourself into the habit of documenting
EVERYTHING… conversations with parents,
phone calls, intervention, etc.
• Don’t rely on your memory… It will fail you
and it won’t be the same as someone else’s
(especially a parent’s)
• Lack of documentation is lethal. Poor
documentation is worse.
Documentation Resources
• ASHA Website
• Moore, B. J. (2010). Documentation for SLPs and Audiologists in Schools.
(Audio Program). Rockville, MD: ASHA.
• Moore, B. (2013). 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. J. (2012, April 03). Five Common Documentation Questions—
Answered. The ASHA Leader.
• 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,
and Answers

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