Documentation in School Settings
Introduction | FAQs | Overview of Relevant Laws | ASHA Resources | References
Documentation is a critical aspect of the job of the school-based SLP, because it can affect outcomes for students receiving services. Documentation practices and procedures are influenced by key ASHA documents that describe SLP scope of practice and roles and responsibilities in schools. Specific requirements are included in state and local regulations and policies as well as federal mandates such as
This section includes commonly asked questions about documentation in schools on topics such as RTI, IEPs, treatment notes and more.
Overview of Relevant Laws
The following section was developed by ASHA member Barbara Moore and includes information (specifically on FERPA and HIPAA) based on her chapter "Documentation Issues" in Professional Issues in Speech-Language Pathology and Audiology (4th ed.). We gratefully acknowledge her contributions to this resource.
The Family Educational Rights and Privacy Act (FERPA) is the federal law that addresses student records, including who can have access to these records. This law ensures that parents have an opportunity to have the records amended and provides families some control over the disclosure of information from the records. According to FERPA, educational records are records that are (a) directly related to the student and (b) maintained by an educational agency or institution or by a party acting for the agency or institution (20 U.S.C. 1232g(a)(4)(A); Moore, 2010). The legislation provides clarification on parental access to student records, in addition to limiting the transfer of records through requiring consent for record transfers.
The Health Insurance Portability and Accountability Act (HIPAA) is the law that pertains to protected health information (PHI). Originally enacted in 1996, the 2003 amendments addressed electronic transmission of records and increased restrictions on accessibility to health records. Because school personnel are often seeking information from health care providers, there is periodically confusion and questions regarding which HIPAA requirements apply in school settings.
Education records are subject to the protections of FERPA and are excluded from HIPAA. The HIPAA privacy rule mandates that a "covered entity" may not use or disclose PHI except as permitted by the rule. A school district is considered the "covered entity." The PHI is germane, in most cases, to conducting evaluation and development of the individualized education program (IEP) and/or 504 plan. Again, the intent of both HIPAA and FERPA is confidentiality. SLPs and audiologists practicing in health care settings will have greater awareness of the influence of HIPAA in their work settings than will those in schools.
Most school records are covered under FERPA and excluded from HIPAA, including IEPs, evaluations, IEP meeting tapes, Medicaid reimbursement claims, student health records, and personal notes, when the personal note has become a school record (Shorter, 2004).
The Individuals with Disabilities Education Improvement Act of 2004 (IDEA 2004) is the federal law in the United States that requires the provision of special education and related services for students who are identified as children with a disability (CWD). The determination of eligibility and types of services required is completed following specific procedures for a multidisciplinary assessment and through an IEP process. When children are determined to have a disability under IDEA 2004, they become members of a protected class in the United States; therefore, they secure procedural safeguards, which are realized in the procedural requirements of special education and are outlined in the law (Moore, 2010b).
No Child Left Behind (NCLB) is the 2002 re-authorization of the Elementary and Secondary Education Act (ESEA), which was originally passed in 1965. The 2002 NCLB instituted provisions of accountability that included establishing subgroups for analyzing adequate yearly progress (AYP) and requiring that teachers be highly qualified, among other measures.
ESEA covers various programs, including Title I, Improving the Academic Achievement of the Disadvantaged; Title II, Preparing, Training, and Recruiting High Quality Teachers and Principals; Title III, Language Instruction for Limited English Proficient Students; and Title X, McKinney-Vento/Homeless Education.
This law is due to be reauthorized, but the time frame for completion is currently unknown. Although the use of the title NCLB is gradually being eliminated, and is expected to be eliminated in the reauthorization, the provisions for accountability are expected to remain, albeit in different form.
The Americans with Disabilities Reauthorization Act of 2009 was originally passed as the Americans with Disabilities Act in 1990 and requires "access to buildings, facilities, and transportation, and includes the provision of auxiliary aides and services to individuals with vision or hearing impairments" (Moore & Montgomery, 2008). ADA (1990) deals with accessibility to public domains (including communication access) and "prohibits discrimination on the basis of disability in employment, programs, and services provided by state and local governments, goods and services provided by private companies, and in commercial facilities." (U.S. Department of Justice, 1999, in Moore & Montgomery, 2008). The reauthorization expands the conditions considered as disabled under the ADA. The provisions of the ADA are closely aligned to Section 504.
Section 504 of the Rehabilitation Act of 1973 has a broader definition of disability than IDEA of 2004. Section 504 of the Rehabilitation Act of 1973 is a federal civil rights law that prohibits discrimination against individuals with disabilities in programs and activities that receive federal financial assistance. Students determined eligible under 504 will have a 504 accommodation plan. See this chart from the National Center for Learning Disabilities (NCLD) comparing Section 504 and IDEA.
Medicaid funds are available to school districts when specific services, such as speech-language services, are provided to eligible children in schools. SLPs and audiologists in schools may be expected to bill for eligible services through Medicaid, so that the school district can collect these funds. Requirements for documentation of services under Medicaid requirements vary from state to state.
The resources below provide information on appropriate documentation pertaining to school-based speech-language pathology services.
ASHA Practice Resources
Documentation for SLPs and Audiologists in Schools
ASHA. (n.d.). Documentation in health care settings. Retrieved from www.asha.org/slp/healthcare/documentation/.
Association of California School Administrators (ACSA). (2006). Handbook of goals and objectives related to state of California content standards. Sacramento, CA: Author.
Moore, B. J. (2010a). Documentation for SLPs and audiologists in schools [Audio program]. Rockville, MD: ASHA.
Moore, B. (in press). Documentation issues. In R. Lubinski & M. Hudson (Eds.), Professional issues in speech-language pathology and audiology (4th ed.). Clifton Park, NY: Delmar.
Moore, B. J. (2010b, October). If it's not documented, it didn't happen. Perspectives on Administration and Supervision, 20, 106–110.
Moore, B. J., & Montgomery, J. K. (2008). Making a difference for America's children: Speech-language pathologists in public schools (2nd ed.). Austin, TX: PRO-ED.
Shorter, T. N. (2004). Understanding HIPAA: A guide to school district privacy obligations. Horsham, PA: LRP Publications