Documentation is a critical vehicle of communication among clinicians, payers (i.e., Medicaid), administrators, and other stakeholders in a student's education and well-being. It should provide clinical information about a student's diagnosis, treatment, and outcomes, and efficiently answer the questions that clinicians, administrators, payers, and/or stakeholders may ask, including those presented below:
Documentation formats vary among education systems, and ASHA does not dictate a single format or timeframe. State or federal agencies governing schools, Medicaid reimbursement, or audiology and speech-language pathology regulations may have specific requirements for documentation. Any documentation must meet state and federal agency requirements. School districts, payers, or employment contractors may have additional requirements. See ASHA State by State for more information.
Strong documentation is critical for making sound decisions for students. As the saying goes, "If you didn't document it, you didn't do it." Unclear, vague, or missing documentation can result in compliance violations, ethical charges, inability to defend decisions in a due process situation, difficulty following the clinical judgment underlying the diagnosis and treatment, and denials for Medicaid reimbursement. Any official student record can be subpoenaed. Strong documentation must be provided for diagnostic, treatment, progress reporting, and consultative services.
Documentation is necessary to ensure compliance with the Individuals with Disabilities Education Improvement Act (IDEA, 2004) and state regulations. High-quality documentation also protects school districts and service providers in mediation and due process situations.
IDEA requires regular progress reports on individualized education program (IEP) goals, which should be based on quantitative and qualitative data.
In order for a student to qualify for services, their communication disorder must have an educational and/or functional impact. Educational impacts may be evident in both academic and "nonacademic" situations and are documented in a variety of ways.
Most service provision is governed by an IEP; however, some students may instead have a 504 plan or a response to intervention plan.
Students may also be receiving services that are reimbursed by Medicaid, requiring additional documentation.
In order to qualify for special education services under IDEA (2004), including those provided by an audiologist or a speech-language pathologist (SLP), a student's disability must also adversely affect educational performance. "Educational performance" is not limited to academic performance but may also include functional, social, and developmental information, in addition to academic information (see IDEA, 2004, Sections 300.304–300.8).
An individualized education program (IEP) is a legal document designed to ensure that a student who is eligible for special education services has individualized and well-defined objectives toward meeting educational goals. The document is developed by a team that, at minimum, includes the general education classroom teacher, parent/guardian, special education teachers and specialized instructional support personnel (SISP), someone knowledgeable about assessment, and a school administrator.
This document must include the following items (see IDEA Regulations):
A description of benchmarks or short-term objectives should be included for students with disabilities who take alternate assessments aligned to alternate achievement standards.
IEP goals should be derived from areas of need identified in an assessment or other method of determining present level of academic achievement or functional performance. Goals must be measurable, must focus on what the student will do, and should relate to the curriculum and standards. It is important that IEP goals are SMART:
The IDEA (2004) requires that a transition plan be included in the IEP that is in effect when the student turns 16, or when the student reaches a younger age than 16, if such an exception is determined appropriate by the IEP team. The timelines indicated for transition services must also include the following stipulations:
Some states may have additional regulations requiring earlier transition planning.
Any changes to the IEP document should be agreed upon, documented, signed off on, and dated by all team members. Accuracy is imperative because the IEP document serves as the foundation for the educational program that will be provided to the student and that will be referenced for future decision making.
There are two ways to make changes to the IEP document:
If changes are made to a student's IEP, the school must ensure that the IEP team is aware of those changes. Although there are provisions in IDEA (2004) that allow changes to be made without a meeting, alterations in IEP services without an IEP meeting can be interpreted as a violation of the student's free appropriate public education (FAPE) and, hence, could have legal consequences. This can be the case even if the parent/guardian verbally agrees that a proposed change is acceptable and that a meeting is not necessary. It is critical to get this agreement in writing. Meaningful parent/guardian involvement is key to successful IEP programming and is required by state and federal regulations. Respecting and following the process allows for documentation of rationale and input by all parties. Without accurate documentation describing the participation of all parties, a district may find it difficult to defend itself against potential parent/guardian challenges.
Parents/guardians are required members of the IEP team. If a parent/guardian is unable to attend in person, options to attend virtually should be provided. Parents/guardians are also entitled to an interpreter at IEP meetings, if needed, to ensure that the parents/guardians understand the proceedings. A parent/guardian may also request a postponement or rescheduling. Any and all efforts to contact the student's parents/guardians and/or offer options for their participation should be documented. Regardless, all documents must be fully completed within the timelines designated by IDEA (2004). For a comprehensive review of these requirements, see IDEA, 2004, Section 34 CFR 300.328.
Services must be provided according to what is agreed upon and documented in the IEP, including the frequency, type, duration, and location of 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 student's needs and progress. Check with your state or district regarding their policies for reporting services. It is important to keep therapy log notes that provide information about when services were provided, what objectives were targeted for each session, and progress data.
At times, Medicaid services are included as part of the FAPE of those students who are eligible. Medically necessary services delivered in the school, such as those provided by an audiologist or an SLP, may be billed to Medicaid. With this in mind, documentation of services in the schools may require demonstration of medical necessity of services as delivered by a qualified provider. Medicaid documentation requirements vary from state to state. State-specific guidelines can be found in the state's Medicaid plan and/or Medicaid guidance documents (e.g., the state provider handbook). For more information, go to ASHA's Medicaid Toolkit web page.
Clinicians may work with students without IEPs (depending on local and state practices) to perform the following tasks:
Each district has a policy on how documentation should be provided for these kinds of activities, but it is important to record the following for each interaction:
Clinicians interface with students without IEPs (depending on local and state practices) as a part of the RTI/MTSS. Within the context of RTI/MTSS, clinicians are involved in screening, identifying instructional goals and strategies, and working face to face for limited periods of time on specific general education objectives. Each district or state establishes its own procedures for documentation and parent/guardian notification of these activities. Identify the documentation expectations in your specific setting.
If the district or state does not have specific procedures, the best rule of thumb is to document the IEP services in the same way that you would for IDEA services, creating a comprehensive set of data that shows the date/time/place when general education support was provided, the goals addressed, and progress achieved.
The audiologist and SLP use documentation to communicate critical information about the student's diagnosis, treatment, progress, and status to other providers and/or stakeholders in the student's education. It is important to secure written permission from the parent/guardian before releasing information to those outside the school setting.
IDEA (2004) requires that an evaluation be comprehensive and assess all areas of suspected disability. It is important for the clinician to involve other assessment staff as part of the multidisciplinary evaluation team to address educational and/or behavioral concerns for students who are not meeting the grade-level expectations (IDEA, 2004, Section 34 CFR 300.304).
The standard format is as follows (see Moore, 2010a, 2010b):
Other considerations in documentation of evaluation and assessment include the data collection procedures, the use of interpreters in test administration, the use of translated testing tools, the language used during assessment for multilingual students, the handling of test protocols, explanation of any nonstandard test administration (i.e., accommodations or modifications), and timelines/deadlines for compliance with IEP development and review.
Refer to state regulations for additional information.
The standard for therapy notes in schools is similar to that for any other work setting for clinicians, in that it documents the service provided and the student's performance. Notes should be clear enough for any reviewer to determine the rationale for treatment, the nature of the treatment, the student's current status, and the next steps toward goal achievement.
Log notes should also be a record of attendance.
The student is dismissed from services when the criteria for eligibility are no longer met. See Eligibility and Dismissal in Schools.
Official school records generally fall into three categories (see Moore, 2010a, 2013):
Please note the following stipulations about types of documentation and their status as records:
Location of student records vary by school district in order to restrict access and ensure confidentiality. Most school districts keep files 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 keep locked file cabinets in their rooms so that their teacher/specialist file can be kept secured.
State and district procedures vary in terms of how long student records need to be maintained, and it also depends on the type of student record.
With regard to retaining documentation, please note the following:
Test protocols are often kept in the clinician's file or in the district's special education file. Consult your district's policies regarding how long and where protocols will be maintained. 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.
The Family Educational Rights and Privacy Act (FERPA, 1974) 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.
Fair use under U.S. Copyright Law permits providing a copy of a child's protocol and/or test results to the parent/guardian because that situation does not infringe on proprietary business rights (i.e., one can assume that the parent/guardian is not going to publish or otherwise misuse the protocol; Newport-Mesa Unified School District v. State of California Department of Education, 2005). Check with your state or district regarding their policies.
Can parents/guardians insert information into an assessment report?
An assessment report is the work of the assessor or assessment team. If the parent/guardian provides evidence of a factual error (e.g., misidentification of the city where the student was born), then the report should be corrected. However, if the parent/guardian disagrees with the report's conclusions or interpretation, the parent/guardian can submit information to be added to the report. School districts have processes and board policies in place for amending student records. Parents/guardians will need to be advised of these procedures if such an issue arises.
How should reports from other agencies be handled?
Reports from other agencies should be considered at an IEP meeting. During the evaluation time period, if an evaluation report is provided from an outside agency, the information should be reviewed and can be incorporated into the school evaluation. The same is true for reports from other providers.
Should e-mail communications be kept in the student file? Are they part of the "official" record? Is the same true of fax confirmations/text messages/postal receipts?
E-mail is considered part of the student record if it is placed in the student's file/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 mentioned in the e-mail message, then that e-mail message is assumed to be part of FERPA. Be judicious with e-mail, and limit the information that you share regarding students.
Should telephone conversations be documented? If so, in what form should phone conversations be documented?
Yes, phone conversations should be documented. Options for the form include
Keep these tips in mind:
What kind of documentation is needed for students who are home schooled? What about for students who are in private school?
Assuming that these students are enrolled in special education, the documentation requirements remain the same. Students who are home schooled or who are enrolled in private school have an individual service plan (rather than an IEP), 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.
Do I have to include my credentials (e.g., CCC-SLP, CCC-A) in my signature?
Educational records are considered a legal document, and the signatures of those who are entering information into this legal document should reflect their role within the organization. The official title of the audiology professional is audiologist, and the official title of the speech-language pathology professional is speech-language pathologist, which may be spelled out or included in the abbreviated credential, CCC-SLP/CCC-A for certified individuals. District rules may also specify the need to include information about licensure or additional credentials. Audiologists or SLPs holding an advanced degree in another discipline, such as psychology or business, should specify their credentials appropriately. See Issues in Ethics: Use of Graduate Doctoral Degrees by Members and Certificate Holders. Members holding specialty certification should also include those credentials.
Does the SLP/audiologist supervisor need to co-sign all documentation completed by a student? What about a Clinical Fellow?
All student documentation is co-signed by a qualified clinician. Clinicians are responsible for identifying and meeting necessary qualifications. The supervisor must also ensure that the student supervisee documents client records in an accurate and timely manner (ASHA, 2010). See ASHA's Practice Portal Page on Clinical Education and Supervision and Issues in Ethics: Supervision of Student Clinicians.
ASHA's requirements for CF supervision do not address record documentation but do require that all CFs follow appropriate state and employer regulations. Review federal and state regulations to determine whether a Clinical Fellow requires a co-signature for documentation. See Issues in Ethics: Responsibilities of Individuals Who Mentor Clinical Fellows in Speech-Language Pathology and Information for Clinical Fellowship (CF) Mentoring SLPs for more information regarding the supervisor's responsibilities.
Clinicians may delegate tasks to students or Clinical Fellows only insofar as those tasks are appropriately supervised (see ASHA Code of Ethics, Principle 1, Rule E). Aspects of documentation that require the unique skills, knowledge, and judgment of the clinician should not be delegated (see ASHA Code of Ethics, Principle 1, Rule F).
State licensure boards and Department of Education policies may vary in the requirements for documentation completed by students and Clinical Fellows.
Can the audiology assistant or speech-language pathology assistant (SLP-A) assistant who works with me document a student's progress in therapy?
No. An audiology assistant or SLP-A may collect data, but the interpreting and reporting of data is the responsibility of the certified or licensed clinician. Clinicians may delegate tasks to support personnel, including audiology assistants or SLP-As, only insofar as those tasks are permitted under state and federal regulations and are appropriately supervised (see ASHA Code of Ethics, Principle 1, Rule E). Aspects of documentation that require the unique skills, knowledge, and judgment of the clinician should not be delegated (see ASHA Code of Ethics, Principle 1, Rule F). See the Speech-Language Pathology Assistant Scope of Practice, ASHA's Practice Portal page on SLP-As, ASHA's Practice Portal page on Audiology Assistants, and ASHA's Code of Ethics. In addition, consult your state's scope and regulations.
Who "owns" the documentation—the clinician who wrote it or the school?
All official documents and records are the property of the school entity.
What should I do when I am asked to complete documentation for a colleague who has moved on if I was not previously involved in the case that is being documented?
Ideally, clinicians will complete all documentation prior to leaving a job and will provide sufficient notice before discontinuing services to those they are serving (see ASHA Code of Ethics, Principle I, Rule T). It may be possible for another clinician to review prior notes and treatment logs to put together the necessary information. The clinician should be clearly identified, and the district may note the treating clinician's departure in the record so that it is clear to anyone reviewing the file. If there is not sufficient information to complete the documentation (such as no record of treatment dates), then the district should make note of that in the record. Attempting to recreate records without sufficient information may result in false information and fraudulent billing.
Are my informal data tallies (e.g., check marks for accurate responses to help me determine progress) considered part of the educational record?
The data tallies that are interpreted elsewhere are generally not considered part of the designated record set. Check marks or other informal means of recording data during the treatment session are likely meaningless to anyone other than the treating clinician; however, the interpretation of those data (e.g., "Student was able to complete cloze sentences with 70% accuracy with minimal cues.") is meaningful and is considered part of the record.
The following legal and ethical documents affect documentation in the schools. Professionals should have a strong understanding of all of these issues.
ASHA's Code of Ethics, Principle 1, Rule O, states: Individuals shall protect the confidentiality and security of records of professional services provided, research and scholarly activities conducted, and products dispensed. Access to these records shall be allowed only when doing so is necessary to protect the welfare of the person or of the community, is legally authorized, or is otherwise required by law (ASHA, 2016).
ASHA's Code of Ethics, Principle 1, Rule P, states: Individuals shall protect the confidentiality of any professional or personal information about persons served professionally or participants involved in research and scholarly activities and may disclose confidential information only when doing so is necessary to protect the welfare of the person or of the community, is legally authorized, or is otherwise required by law (ASHA, 2016).
ASHA's Code of Ethics, Principle 1, Rule Q, states: Individuals shall maintain timely records and accurately record and bill for services provided and products dispensed and shall not misrepresent services provided, products dispensed, or research and scholarly activities conducted (ASHA, 2016).
The U.S. Department of Education, the state department of education, and districts may impose their own requirements for documentation.
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 to be disabilities under the ADA. The provisions of the ADA are closely aligned to Section 504.
The Every Student Succeeds Act (ESSA), which became law in December 2015, replaced the No Child Left Behind Act (NCLB). The 2002 NCLB instituted provisions of accountability that included establishing subgroups for analyzing adequate yearly progress (AYP) and requiring that teachers be highly qualified. The goal of ESSA is to create a better law focused on the clear goal of fully preparing all students for success in college and careers.
ESSA covers various programs, including Title I, Improving Basic Programs Operated by State and Local Educational Agencies; Title II, Preparing, Training, and Recruiting High-Quality Teachers, Principals, and other School Leaders; and Title III, Language Instruction for English Language Learners and Immigrant Students.
For more information, see Every Student Succeeds Act: Key Issues for ASHA Members.
The Family Educational Rights and Privacy Act (FERPA) (1974) is the federal law that addresses student records, including who can have access to these records. This law ensures that parents/guardians 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 defined as 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, 2010b]. The legislation provides clarification on parental access to student records and limits the transfer of records by requiring consent for record transfers.
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/guardians "to inspect and review the student's education records" (Section 99.7). The law requires that schools establish procedures enabling parents/guardians to review their children's records within a reasonable time after a request is made. FERPA requires that a copy be provided only where a parent/guardian would not otherwise be able to review the student's record (e.g., a parent/guardian is disabled and cannot travel to the school).
The Individuals with Disabilities Education Improvement Act of 2004 (IDEA, 2004) is the U.S. law 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 students 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).
Although IDEA is a federal regulation, each state has created regulations that interpret the law for their particular state. Although state regulations cannot require less than what is required by the federal regulation, it can require more, so it is important to understand your state's regulations for special education.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is the law that pertains to protected health information (PHI). The law was originally enacted in 1996 and was amended in 2003. 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 or billing Medicaid, periodically there is confusion and there are questions regarding which HIPAA requirements apply in school settings.
In most cases, HIPAA privacy rules do not apply to public schools because the school either is not a HIPAA-covered entity or is a HIPAA-covered entity whose health information is maintained in the education records, which fall under FERPA.
Records shared via electronic transmission fall under FERPA. The clinician must follow FERPA and receive permission from the parents/guardians to send records and bill Medicaid (34 CFR 99.30). At the time, the records are sent to Medicaid, and then that transaction falls under HIPAA.
A private school that is not receiving funding from the U.S. Department of Education and that contracts a therapist to provide services must follow HIPAA. An exception would be when a student in public school is placed in a private school; in this situation, the private school is required to follow FERPA for that student.
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. In most cases, the PHI is germane to conducting evaluation and development of the IEP and/or Section 504 plan. Again, the intent of both HIPAA and FERPA is confidentiality.
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 who are determined eligible under Section 504 will have a Section 504 accommodation plan. See this chart from the Understood Program at the National Center for Learning Disabilities (NCLD) comparing Section 504 and IDEA.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
American Speech-Language-Hearing Association. (2010). Responsibilities of individuals who mentor clinical fellows in speech-language pathology [Issues in Ethics]. Retrieved from www.asha.org/Practice/ethics/Responsibilities-of-Individuals-Who-Mentor-Clinical-Fellows-in-Speech-Language-Pathology/
American Speech-Language-Hearing Association. (2016). Code of ethics [Ethics]. Available from www.asha.org/policy/.
Americans With Disabilities Act of 1990, Pub. L. No. 101-336, 104 Stat. 328 (1990).
Family Educational Rights and Privacy Act of 1974, 20 U.S.C. § 1232g (1974).
Health Insurance Portability and Accountability Act of 1996. Pub. L. No. 104-191, 110 Stat. 1938 (1996).
Individuals With Disabilities Education Act, 20 U.S.C. § 1400 (2004).
Moore, B. J. (2010a). Documentation for SLPs and audiologists in schools [Audio program]. Rockville, MD: American Speech-Language-Hearing Association.
Moore, B. J. (2010b). If it's not documented, it didn't happen. Perspectives on Administration and Supervision, 20, 106–110.
Moore, B. (2013). Documentation issues. In R. Lubinski & M. Hudson (Eds.), Professional issues in speech-language pathology and audiology (4th ed.; pp. 420–443). Clifton Park, NY: Delmar.
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.
Newport-Mesa Unified School District v. State of California Department of Education, 371 F. Supp. 2d 1170 (2005).
Rehabilitation Act of 1973, Section 504. Pub. L. No. 93-112, 87 Stat. 394 (Sept. 26, 1973), codified at 29 U.S.C. § 701.
Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the page:
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Documentation in Schools (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Documentation-in-Schools/.