These FAQs are based on excerpts from federal laws and best practice information. The information provided is not intended to be legal advice. If legal advice is needed, please contact a licensed attorney.
For additional clarification on documentation questions, check with your state or local education agency and/or refer to the applicable federal law(s). Questions about this resource can be directed to firstname.lastname@example.org.
The following section was developed by ASHA member Barbara Moore with input from the ASHA School Services staff and other sources. We gratefully acknowledge Dr. Moore's contributions to this resource.
There is no requirement to take minutes for the IEP meeting; in fact, minutes should not be taken. What is recommended is taking notes that document what happened during the meeting. Specifically, notes should document that the appropriate process was followed, including important actions such as:
The IEP notes are not intended to be a verbatim transcript of the meeting, but rather a summary of the actions held. Several important matters to cover in your notes are
A good practice is to read the notes at the conclusion of the meeting to be sure they accurately reflect what happened and capture important professional practices you followed. If the parent(s) want to add something, or they disagree with the SLP, they can provide information in writing that can be attached to the IEP. If a parent points out an error, you should correct it. However, it is not appropriate to make other changes: The IEP is the district's document, so it should not be changed or given to the parent to complete.
There are several ways to make changes to the IEP.
If changes are made to a child's IEP, the school must ensure that the IEP team and the parent(s) are informed of those changes. Districts have forms for this purpose. For IEP team meetings, the parent(s) and the school may agree to use alternative means of meeting participation, such as video conferences and conference calls. See IDEA Section 34 CFR 300.324(a)(4)(i). Although there are provisions in IDEA 2004 to allow changes to be made without a meeting, we recommend that you always contact a supervisor before doing this. Changes or alterations in IEP services without an IEP meeting can be held to be a violation of the child's FAPE and, hence, could have legal consequences. This can be the case even if the parent verbally agrees that a proposed change is acceptable and that a meeting is not necessary.
Meaningful parent involvement is key to successful IEP programming. Otherwise, parents may not feel confident that they understand, or have fully participated in, making the recommended changes. Scheduling meetings can be a challenge, but parents in particular can benefit from a team discussion of issues such as increasing services, changing service delivery models, discontinuing services, or behaviorally related problems. Respecting and following the process allows for documentation of rationale and input by all parties and helps avoid misunderstandings. Without this kind of documentation, a district may find it difficult to defend itself against potential parental challenges.
Parents are required members of the IEP team. If a parent does not come to an IEP meeting, then the meeting should not be held. Each school district has procedures for parent notification and what to do if the parent does not come to the meeting. Typically, multiple attempts are made to contact the parent, and options are offered to find a mutually agreeable meeting time. Such efforts include phone calls during evening hours, registered or certified mail, and offers for video conferences or conference calls which are permissible alternate means of meeting participation.
If all such attempts have failed, it is wise to obtain a supervisor's approval before holding an IEP meeting without parents present. Also, in such cases, you should document in the IEP all attempts to contact the parent and should mail the IEP to the parent by certified or registered mail. For a comprehensive review of these requirements see IDEA Section 34 CFR 300.328.
In short, no. Services must be provided according to what is agreed to in the IEP. Using the ASHA Workload Analysis Approach for documenting services per month or per quarter allows for greater flexibility and is a highly desirable way to document services. Some districts accept minutes per reporting period or semester as an acceptable means of recording frequency and duration of services. The IEP could also indicate how the frequency and location of services may change depending on the child's needs and progress. Check with your state or district regarding their policies for reporting services.
IEP goals should be derived from an area of need identified in an assessment or other method of determining present level of academic achievement or functional performance. Goals must be measurable and need to focus on what the student will do. The American Association of California School Administrators (ACSA, 2006) provides the following six questions to answer when writing IEP goals:
School records generally fall into three categories (see Moore, 2010a, as cited in Moore, in press):
Types of documentation and their status as records include the following:
School districts vary in terms of where pupil records are kept. The main goal is to restrict access to ensure confidentiality. Most school districts have a system whereby the files are kept in locked file cabinets with limited access. Often, lists with the names of those who can have access to the student records are posted on the file cabinets. Most special educators have locked file cabinets in their rooms, so that their teacher/specialist file can be kept secured.
State and district procedures vary on this, and it also depends on the type of student record.
With regard to retaining documentation, please note the following:
The standard for therapy notes in schools is no different from that for any other work setting for SLPs or audiologists. Most important, notes should document service provided and student performance.
For billing purposes, you may want to review requirements for clinical therapy notes for Medicaid. The SOAP note format (Subjective/Objective/Assessment/Plan) is not always used in school settings, but is a good method to ensure your notes include all appropriate information (Moore, in press).
Remember that whether it is an auditor or an attorney who reviews your notes, what happened in the session should be clear. Consider whether another SLP could read the notes and accurately determine what to do next.
Assessment reports generally follow this standard format (see Moore, 2010a, 2010b, as cited in Moore, in press):
An assessment report is the work of the assessor or assessment team. The parent cannot insert information into the assessment report. If the parent provides evidence of a factual error (e.g., misidentification of the city where the child was born), then the report should be corrected. However, if the parent disagrees with conclusions or interpretation, the parent can submit documentation for the file; the assessor does not need to change the report. School districts have processes and board policies for amending student records. Parents will need to be advised of these procedures if there is such an issue.
Reports from other agencies should be considered at an IEP meeting. The same is true for reports from other providers.
E-mail is considered part of the student record if it is placed in the student record. E-mail, text messages, and other electronic communications can be subpoenaed regardless of whether they are part of the student record. Fax confirmations and postal receipts would be considered appropriate to be included in the student file. All content with personally identifiable information (PII) is considered part of the student record, so if the student's name is in the e-mail, it is assumed to be part of FERPA. Be judicious with e-mail and limit information shared regarding students.
Yes, phone conversations should be documented. Options for the form include
Keep these tips in mind:
Test protocols are often kept in the teacher/specialist file or in the district's special education file. Consult your district's policies for how long and where protocols will be maintained.
No, once the protocol has been completed, it becomes a student record and cannot be destroyed until the appropriate time, as prescribed by record destruction procedures.
Under FERPA, there is a difference between allowing access to records and providing copies. FERPA does not require that copies of documents be provided. Rather, FERPA establishes the right of parents "to inspect and review the education records of their children." The law requires schools establish procedures that enable parents to review their children's records within a reasonable time after a request is made. FERPA requires a copy be provided only where a parent would not otherwise be able to review the student's record (e.g., a parent is disabled and cannot travel to the school).
FERPA neither requires nor prohibits the sharing of test protocols. FERPA also does not define specifically what constitutes the official "student record." Those decisions are left to states and local agencies. However, any document that is considered a part of an official student record is then protected under FERPA.
Recent court cases support the fact that it is NOT a copyright violation to provide a copy of a protocol to a parent, because that situation does not infringe on proprietary business rights (i.e., one can assume the parent is not going to publish, or otherwise misuse the protocol). Check with your state or district regarding their policies.
Because there is wide variability in how RTI services are provided, the best rule of thumb is to document the same way you would for IDEA services.
Assuming that these students are special education students, the documentation requirements remain the same. Private school students may have a service plan, but the documentation requirements in terms of treatment are the same. States vary in their requirements, so check with your local district on these issues.