Documentation in Schools

Overview

Documentation is a primary method of communication between clinicians (i.e., audiologists and speech-language pathologists), payers (i.e., Medicaid), administrators, and other stakeholders involved in a student’s education and social–emotional needs. Complete documentation is a requirement to ensure compliance with provision of a student’s individualized education program (IEP) and 504 plan.

Documentation formats vary among education systems, and ASHA does not recommend or suggest a single format or timeline. State or federal agencies governing schools, Medicaid reimbursement policies, or audiology and speech-language pathology regulations may have specific requirements for documentation. Any documentation must meet state and federal agency requirements. School districts or payers may have additional requirements. See ASHA State-by-State for more information.

Thorough and consistent documentation is critical for making appropriate decisions for students. Unclear, vague, or missing documentation can result in compliance violations, ethical charges, the inability to defend decisions in a due process hearing, difficulty following the clinical judgment underlying the diagnosis and treatment of the underlying disability, and denials for Medicaid reimbursement. Thorough documentation may help protect school districts and service providers in mediation and due process situations by demonstrating adherence to legal requirements and evidence-based practice of the field. Any official student record can be reviewed and discussed for legal purposes, such as due process complaints and hearing office determinations. It is, therefore, important that documentation aligns with the prescribed services on the IEP (dosage) and complies (i.e., addresses identified goals) with the IEP. Documentation must connect identified student needs based on diagnosis, results of assessment in all areas of suspected disability, eligibility determination, development of goals, and recommendation for treatment services, including the service delivery model.

Translation of documents for multilingual students and parents should be provided as necessary, including, but not limited to, IEP documentation. This is a requirement of the Individuals With Disabilities Education Improvement Act of 2004, but clinicians should follow local (e.g., school district) policies and processes for these requests (U.S. Department of Justice & U.S. Department of Education, n.d.). Clinicians should be careful to use the appropriate pronouns in documentation (e.g., “they” as opposed to “he” or “she”) or to use the child’s first name instead.

Key Issues

Documentation Principles in Schools

Documentation is necessary to ensure compliance with the Individuals with Disabilities Education Improvement Act of 2004 (IDEA) and state regulations. There are many different types of documentation in schools, including assessment reports, individualized education program (IEP) documents, and regular progress reports of IEP goals, all of which should be based on quantitative and qualitative data.

The student’s disability must have an adverse effect on their academic or functional performance to be found eligible for special education services by meeting eligibility for one of the 13 disabling conditions. After making an eligibility determination, the IEP team must determine student needs and goals, then the team will determine if the student needs audiology or speech-language pathology services. In the multidisciplinary assessment, the identification of a student’s needs will lead to the establishment of goals and, ultimately, the determination of services needed to address these goals. Areas of need in communication impact educational progress and development. 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, §§ 300.304–300.8).

Most school-based audiology and speech and language services are provided through an IEP; however, some students may instead have a 504 plan. The IEP/504 services that some students receive may be reimbursed by Medicaid, which may require additional documentation by the audiologist and/or speech-language pathologist (SLP). Please see Medicaid reimbursement in schools for further details.

The educational team determines the presence of a communication disorder and if a student requires services. The team does this by engaging in a thorough review by analyzing existing data points (e.g., assessments, work samples, classroom observations, teacher reports, attendance) to identify areas of need and educational impact. This analysis may help determine if there is an adverse impact on educational performance.

Students who are homeschooled or are enrolled in private school may have an individual service plan rather than an IEP, but the documentation requirements for assessment and intervention are the same. Requirements vary from state to state and from school district to school district.

Educational records are considered a legal document, and the signatures of those who enter 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 (i.e., CCC-A [Certificate of Clinical Competence in Audiology] or CCC-SLP [Certificate of Clinical Competence in Speech-Language Pathology], respectively) for certified individuals. District policies 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.

Student-Centered Documentation

The audiologist and SLP should be mindful of the language used to describe the student when documenting services and writing assessment reports. The clinician/practitioner’s wording should appropriately reflect the name a student prefers to use or how they perceive themselves. There will be times when personal information (e.g., name and pronoun) used during clinical interactions is not consistent with the student records. Clinicians use the name and pronoun provided to them by the student. It is also important to verify the correct name and pronoun to use outside of clinical interactions, such as in documentation, in classrooms, in the hallways, and during IEP conferences. Only information that is relevant to assessment and treatment needs to be reflected in the documentation. Please see the section below on the Family Educational Rights and Privacy Act of 1974 (FERPA) for how a student’s privacy is maintained. Considerations when documenting information for school records include, but are not limited to, the following:

Use of nicknames or chosen names
- It is helpful to clarify that a student’s nickname or chosen name will be used throughout an assessment report, if applicable (e.g., Jonathan “Jon” Doe). Clinicians verify which name to use in documentation with the student. If the student does not want to use their chosen name in documentation, clinicians may consider replacing their legal name with the term “the student” or initials to avoid deadnaming, as appropriate.
Use of pronouns
- Clinicians verify the correct pronoun to use with students during clinical interactions, in documentation, during meetings, and in the classroom. There may be times when students’ pronouns do not align with the sex identified in the student records. Be mindful to use appropriate pronouns consistently throughout documentation. If unsure, use “they” (as opposed to “he” or “she”), the child’s first name, or a general noun such as “the student.”
Use of person-first language or identity-first language
- Each individual has the right to determine how to refer to themselves. Some students may describe themselves with person-first language (e.g., “a student with autism”), whereas others may use identity-first language (e.g., “autistic student”). Note the student’s preference in the record.

Students’ names, pronouns, and preferred language (i.e., person-first vs. identity-first) may change over time. Clinicians should continue to verify personal information on a periodic basis.

Student records also include identification numbers to minimize confusion when a student’s name is the same as that of another student in the system or when their names change. Checking the student record to ensure that numbers and names are correct is good practice and helps protect the student’s confidentiality. Additionally, there may be times (e.g., when contacting family members or external service providers) when a student may not want their chosen name and/or pronouns used. If a clinician is unsure about a particular context, they should seek verification from the student to protect confidentiality. For more information, see Supporting and Working With Transgender and Gender-Diverse People and Supporting Chosen Names and Pronouns.

IEP

An IEP is a legal document designed to ensure that a student who is determined eligible for special education due to a disabling condition receives the services that they are entitled to by IDEA (2004). The IEP document is developed following an assessment in all areas of suspected disability, which leads to a conclusion about eligibility and the identification of need. The IEP team then sets educational or functional goals that may have benchmarks or objectives so that measurement toward meeting the goals can be tracked. The IEP document is developed by an educational team that, at minimum, includes the general education classroom teacher, the parent/guardian, special education teachers and specialized instructional support personnel, someone knowledgeable about assessment, and a school administrator.

This document must include the following items (see IDEA Regulations; IDEA, 2004):

A description of benchmarks or short-term objectives should be included for students with disabilities who are unable to engage in standardized testing due to their disability. These students may take alternate assessments aligned to alternate achievement standards.

IEP goals may be derived from areas of need identified from an assessment or alternative method of determining present level of academic achievement or functional performance. Goals should be measurable and should focus on areas of need impacting the student’s academic and functional performance. Goals are typically represented as percentage accuracy or number of trials completed successfully. These goals should relate to the curriculum and standards. It is important that IEP goals are SMART:

Specific
Measurable (how they are measured, under what conditions, by what date)
Achievable (in 1 year)
Relevant to education
Time limited

Please see ASHA’s resource on writing measurable goals and objectives [PDF] for tools/templates related to goal writing.

IDEA (2004) requires that the IEP include a transition plan that is in effect when the student turns 16 years old. The transition plan may begin at an age younger than 16 years if such an exception is determined appropriate by the IEP team or is required based on state regulations. The timelines indicated for transition services must also include

appropriate measurable postsecondary goals based on age-appropriate transition assessments related to training; education; employment; and, where appropriate, independent living skills and
the transition services (including courses of study) needed to assist the student in reaching those goals.

Some states may have additional regulations requiring earlier transition planning. Please see ASHA’s resource on individualized education programs (IEPs), individualized family service plans (IFSPs), and section 504 plans for further information.

[1] Several acronyms may be used interchangeably, including present level of performance (PLOP or PLP), present level of educational performance (PLEP), and present level of academic achievement and functional performance (PLAAFP).

Documenting Modifications to the IEP

Any changes to the IEP document should be agreed upon, documented, signed, and dated by all team members. Accuracy is important because the IEP document serves as the foundation for the educational program that will be provided to the student and is the document that will be referenced for future decision making.

There are two ways to make changes to the IEP document:

The entire IEP team can modify the plan at an IEP team meeting.
The parent/guardian and the school may agree not to convene an IEP team meeting to make changes and, instead, may develop a written document to amend or modify the IEP. These changes may need to be initialed or otherwise acknowledged by the parent/guardian.

The school must ensure that the IEP team is aware of any changes that are made to a student’s IEP. Alterations in IEP services without an IEP meeting can be interpreted as a violation of the student’s free appropriate public education and could have legal consequences despite provisions in IDEA (2004) that allow changes to be made without a meeting. 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 important to document such an agreement in writing, typically via a prior written notice. Respecting and following the process allows for documentation of rationale and meaningful input by all parties. A district may find it difficult to defend itself against potential parent/guardian challenge and/or lawyer/advocate complaints without accurate documentation describing the participation of all parties.

Parent/Guardian Involvement in the IEP Process

Parents/guardians are required members of the IEP team. Parent/guardian involvement in the IEP process is outlined in the procedural safeguards document provided to parents in IEP meetings that outlines the process and their rights. Meaningful parent/guardian involvement is key to successful IEP programming and is required by state and federal regulations. Options to attend virtually should be provided if a parent/guardian is unable to attend in person. Parents/guardians are also entitled to an interpreter, if needed, at IEP meetings to ensure that the parents/guardians understand and can actively participate in the proceedings. A parent/guardian may also request a postponement or rescheduling. 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), 34 C.F.R. § 300.328. Current best practice is to provide documentation pertinent to the IEP to parents/guardians at least 5 days prior to an IEP meeting or in alignment with a given school, state, or school district policy.

Service Provision According to the IEP

Services are 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 on the IEP document. The IEP may also indicate how the frequency and location of services may change depending on the student’s needs and progress. Clinicians may check with their state or district regarding their policies for reporting services. Many districts have electronic systems to document when services are provided. Failure to document service provision can potentially lead to allegations of failure to implement the IEP, which could be a due process issue. It is important to keep therapy log notes that provide information about when services were provided and what objectives were targeted for each session as well as data on the student’s progress.

Medicaid

Medicaid services may be included as part of the free appropriate public education 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. 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.

Documenting Services for Students Without IEPs

Clinicians may work with students without IEPs (depending on local and state practices) to

provide supports within the context of multi-tiered systems of support (MTSS) or response to intervention (RTI);
monitor and ensure that students on a 504 plan receive appropriate services and supports related to communication or hearing needs;
provide screenings and consultation (see ASHA’s Practice Portal page on Childhood Hearing Screening for more information); and
provide expertise to staff and families regarding students who are at risk for communication or hearing disorders, which may include in-service training or teacher consultation.

Each district should have a policy on how documentation should be provided for these kinds of activities, but it is important to record the following for each interaction:

purpose
date and time
assistance provided
student success data
recommendations for treatment services and supports

Documenting MTSS/RTI

MTSS refers to the structure of intervention processes and programs designed to provide universal and systematic progress monitoring and appropriate interventions within tiers of intervention for all students in a school. RTI refers to processes and intervention supports and programs within MTSS that track how students respond to a specific intervention designed for their specific needs. RTI is used to provide services at increasing difficulty and/or intensity levels. Clinicians may be involved with students without IEPs (depending on local and state practices) as a part of the MTSS/RTI. Within the context of RTI/MTSS, clinicians are involved in screening, identifying instructional goals and strategies, and providing direct or indirect (e.g., consultative, periodic progress monitoring) services 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. Clinicians identify the documentation expectations in their specific setting.

If the district or state does not have specific procedures, clinicians may document the MTSS/RTI services in the same way as they would for IDEA (or IEP) services. This creates a comprehensive set of data that shows the date/time/place when general education support was provided, the goals were addressed, and progress was achieved.

Types of Documentation

Audiologists and SLPs use documentation to communicate critical information about the student’s educational programming to other providers and/or stakeholders. It is important to obtain written permission from the parent/guardian before releasing information to those outside the school setting.

Multidisciplinary Assessment and Evaluation

IDEA (2004, 34 C.F.R. § 300.304) requires that an evaluation be comprehensive and assess all areas of suspected disability. It is important for the clinician to coordinate with assessment personnel as part of the multidisciplinary assessment team to address educational and/or behavioral concerns for students who are not meeting grade-level expectations.

The standard assessment format is as follows (see Moore, 2010a, 2010b):

Documentation of evaluation and assessment also includes data collection procedures, the use of interpreters in test administration, the use of translated testing tools, the language used during assessment for multilingual students, maintenance of test protocols, explanation of any nonstandard test administration (i.e., accommodations or modifications), and timelines/deadlines for compliance with IEP development and review. An interpreter may be required when conducting an assessment for a multilingual student. Given these circumstances, the audiologist or SLP documents and accounts for this accommodation within the assessment report. Audiologists and SLPs do not document standardized scores when collaborating with an interpreter and rely on qualitative descriptions of performance on the assessment procedure/tool.

An assessment report is the work of the assessor or assessment team. If a 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 a parent/guardian disagrees with the report’s conclusions or interpretation, a parent/guardian can submit information to be added to the report. Parents can request addition or redaction of information from assessment reports. 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.

There are times when parents/caregivers may provide an outside report or the school district agrees to provide funding for a third-party evaluator to complete an outside assessment for a student (when not in agreement with the findings of district-ordered assessment). These are often referred to as an “independent educational evaluation” or “independent assessment.” The IEP team is required to review the information from independent assessments and considers the information when developing goals and services of the IEP for a student. The IEP team does not need to change any part of the IEP goals and services if no new information is provided or if the information is inconsistent with the school team’s knowledge of the student. The parent may seek reimbursement for the independent assessments. This is not within the purview of the IEP team to resolve. Refer to state regulations for additional information.

Documentation Considerations for English Learners/Dual Language Learners (DLLs)

DLLs (also commonly referred to as English learners, multilingual students, and emergent bilinguals) are among the fastest growing populations in U.S. schools. DLLs comprise over 10% of the student population nationwide and may account for an even higher percentage of the student population in many schools, local educational agencies, and states. DLLs are a highly diverse group of students, with valuable cultural and linguistic assets, including a variety of heritage languages (see Non-Regulatory Guidance: English Learners and Title III of the Elementary and Secondary Education Act (ESEA), as amended by the Every Student Succeeds Act (ESSA) [PDF]; U.S. Department of Education, 2016). Some DLLs also participate in dual language programs or are in bilingual educational settings where the language of instruction is English and an additional language. Therefore, it is important to consider their diverse linguistic and cultural qualities to meet legislative mandates and to guide the delivery of appropriate special education (Hoover et al., 2019).

Important considerations when developing documentation for DLLs with disabilities in schools include, but are not limited to, the following:

Attention to these considerations assists school-based audiologists and SLPs in providing culturally and linguistically responsive services and documentation for DLLs with language-learning disabilities and their families.

Documentation for Treatment Interventions

A treatment note is a document that is created per treatment session with a student, whereas a progress report is a summation of advancement toward goals for a particular time period of treatment for that student (e.g., quarterly IEP report cards).

Treatment Notes

The standard for therapy notes in schools is similar to that of other clinical settings—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. Notes should provide both qualitative and quantitative description of the student’s performance during each intervention session. The documentation should reflect the activities the student engaged in during each session. These activities should be in alignment with the goals on the student’s IEP. Treatment notes verify that the student was present to receive services and should quantify the amount of services (minutes) provided during the intervention session. In some settings, treatment notes indicate how the service was provided (e.g., group vs. individual, inside general education setting vs. outside general education setting). The maintenance of treatment notes also assists with documenting students’ attendance, participation and engagement, and anecdotal information that may impact students’ performance toward their goals (e.g., behavior, level/need for prompting).

Data collection methods record students’ performance during the activities of the intervention session towards their progress on their IEP goals. Check marks or other informal means of recording data during the treatment session assist the treating clinician with maintaining records and comparing performance across intervention sessions to determine the degree of progress towards achieving the goals on the student’s IEP. These are generally not considered part of the designated record set. However, the interpretation and summarization of the data collected is used to write treatment notes and progress reports. 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. SLPs should maintain an ongoing record of data, as this information may be requested by parents/advocates, for litigation proceedings, and/or for district-wide audits.

Progress Reports

IDEA requires regular progress reports that may take the form of quarterly progress reports or IEP reports. These reports update parents on a student’s progress toward goals. The audiologist or SLP should provide qualitative and quantitative information regarding this progress. Other considerations may be made to document progress for students who are in audiology or speech-language pathology treatment but do not have an IEP (e.g., students in private schools).

Dismissal Documentation

The student is dismissed from services when the student has met their goals and no longer demonstrates the need for services to address communication needs. See ASHA’s resource on eligibility and dismissal in schools. Some school districts require reassessment to be completed prior to dismissal. Documentation should support if the student has mastered their goals or has maximized the benefit of services provided. Documentation records provide supporting information for dismissal recommendations by recording performance in sessions and a child’s overall progress.

Documenting Communications

Communication with parents, guardians, and others with authorization to receive communication and/or information about the student should be documented. Parental consent must be obtained for all communication with individuals other than the parents or school personnel with a legitimate educational purpose for knowing about the student’s case. Although grandparents, babysitters, and private service providers may contact school personnel, communication with them about the student can only occur if there is a document giving permission to discuss the student’s case. Options for the form of documentation used include electronic or paper files or recording files (e.g., generated by a web conferencing program). Recording files can be included in the student’s electronic record or transcribed.

Although e-mail, texting, and social media are common forms of communication, school-based personnel are strongly encouraged to use caution with these methods of communication when discussing documentation and IEP or service delivery changes. These methods of communication are generally not compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and FERPA and are therefore not secure in terms of privacy (see the Privacy section below). Also, these communications can easily be forwarded to parties who do not have approval to be part of the conversation. Finally, discussions pertaining to the student’s behavior and functioning are made within approved processes.

Please note the following suggested practices:

Include the time and date (including the year) and identify participants for each record.
For recorded conversations, make sure all participants are aware that the conversation is being recorded and provide documented consent. Permission to record a conversation is legally required in many states. If a clinician is unsure about your state’s stance, they may obtain permission from all parties prior to recording the conversation or research the matter in advance of the call, conversation, or meeting.
Ensure that all recorded conversations, including recordings of IEPs, are transcribed and entered into the record.
Do not agree to have a phone call or videoconference recorded unless there is approval from the district and legal counsel if necessary.

Privacy

Clinicians should refer to FERPA regarding privacy concerns (please see the FERPA section below for further details). However, there may be additional district or school-based privacy rules that impact how documentation is addressed. All documentation that includes personally identifiable information is considered part of the student record. Best practice indicates use of initials in place of students’ names and avoidance of using any identifiable information (e.g., date of birth, address) in documentation whenever possible.

Emails can contain identifiable information about the student even though they may not be officially considered to be a part of a student’s file. Transmission may be encrypted, and/or the audiologist or SLP should not include identifiable information within the correspondence when sending and responding to emails. Communications such as emails, text messages, and other electronic communications can be subpoenaed regardless of whether they are part of the student record. If a student’s name is mentioned in an email message, that message therein falls under FERPA rules.

When describing the different types of official school records, they generally fall into three categories as denoted below (see Moore, 2010a, 2013). Based on the type of school record, it is important to recognize that these records can be accessed to verify the provision of services, student information, and student performance.

Mandatory permanent student records
- may be required by state law and
- usually include identifying information about the student, when the student attended schools in the district, records of subjects taken, grades, immunizations, and the date of graduation or exit.
Mandatory interim student records
- may be required by state law (see ASHA State-by-State);
- are held for a stipulated period of time; and
- may include health information, special education information, language training records, progress reports, parental restrictions, parent/guardian and student challenges to records, parent/guardian authorizations/prohibitions for student participation in certain programs, and results of standardized tests.
Permitted student records
- may include counselor/teacher rating scales, standardized tests older than 3 years, routine discipline, behavioral reports, discipline notices, and attendance records.

Record Retention

All official documents and records are the property of the school district or entity (if not a public school). They must be stored in folders and/or within the online documentation system(s) used by the school district, which should be secured (e.g., locked cabinet, encrypted online database). These records need to remain accessible to assist transitioning between providers/audiologists/SLPs and in case they are needed for review for a due process complaint.

The location of student records varies by school district 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. Special educators may keep locked file cabinets in their rooms so that their teacher/specialist files can be kept secure.

State and district procedures vary in terms of how long student records need to be maintained and depend on the type of student record.

Mandatory student records, such as transcripts, should never be destroyed.
Special education record retention varies by state and district.
If a student leaves the district due to relocation, some records are typically sent to the new district (records must follow the student, but standard practice for which records are sent varies from state to state).
Clinicians check with their local district administration about applicable procedures for teacher/clinician files when a student is no longer on their caseload or at their school.

Please take note of the following regarding retaining documentation:

State Medicaid for school-based reimbursement may require a different length of time for records (documentation) to be kept. Please check with your district Medicaid administrator to confirm the length-of-time requirement.
Confidential records should be securely disposed of by shredding the documents rather than discarding/recycling them. Refer to your district’s policy on providing public notification before records are destroyed.

Please note the following stipulations about types of documentation and their status as records:

Treatment notes or progress notes and Section 504 (Rehabilitation Act of 1973) accommodation plans are considered school records.
Lesson plans are not considered school records.
Notes taken as personal memory aids may be considered “sole possession” notes or may be considered part of the student record, depending on the circumstance. It is best to assume that personal notes can and will be subpoenaed and to be cautious about how such notes are maintained.
Notes to parents/guardians and personal notes are not considered school records unless they are placed in the student’s file or shared with others. However, it is best to assume that any e-mail or document that includes a student’s personal identification information is considered part of the student’s record. See Letter to Mr. Otter [PDF] for more information.
Typically, any information shared with a parent/guardian or other school personnel can be considered part of a student’s record.

Test Protocols

Test protocols are often kept in the clinician’s file or in the district’s special education file. Clinicians may consult their 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.

FERPA neither requires nor prohibits the sharing of test protocols. FERPA also does not specifically define 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 protected under FERPA.

Fair use under the U.S. copyright law permits providing a copy of a child’s protocol and/or test results to that child’s 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.

Although a copy of the summary of the test results may be provided, the specifics of the test (e.g., stimulus items) should not be released to the parent/guardian to preserve the confidentiality of stimulus items.

Documentation for Supervision

It is important to be aware that the supervising clinical educator has several areas where additional documentation may be warranted when SLPs provide supervision to Clinical Fellows (CFs) or when audiologists and SLPs provide supervision to interns, final-year externs, assistants, and/or students. Clinicians may delegate tasks only if those assigned the tasks are adequately prepared and appropriately supervised (see ASHA Code of Ethics, Principle 1, Rule E). Aspects of documentation that require the unique skills, knowledge, judgment, or credentials 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 CFs.

Students

All student documentation is cosigned by a qualified clinician. Clinicians are responsible for identifying and meeting the 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 pages on Clinical Education and Supervision and Issues in Ethics: Supervision of Student Clinicians .

CFs

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 CF requires a co-signature for documentation. See Issues in Ethics: Responsibilities of Individuals Who Mentor Clinical Fellows in Speech-Language Pathology and A Guide to the ASHA Clinical Fellowship Experience for more information regarding the supervisor’s responsibilities.

Audiology Assistants and Speech-Language Pathology Assistants (SLP-As)

An audiology assistant or an SLP-A may collect data, but the interpreting and reporting of data is the responsibility of a certified or licensed clinician. Clinicians may delegate tasks to support personnel, including audiology assistants or SLP-As, only if 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). For further information, see Scope of Practice for the Speech-Language Pathology Assistant (SLPA) and ASHA’s Practice Portal pages on Speech-Language Pathology Assistants and Audiology Assistants. In addition, clinicians may consult their state’s scope and regulations.

Legal and Ethical Issues

The following legal and ethical documents affect documentation in the schools. Professionals should have a strong understanding of these issues.

Ethics

ASHA’s Code of Ethics, Principle I, 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 I, 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 I, 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).

ASHA’s Code of Ethics, Principle III, Rule G, states: “Individuals shall not knowingly make false financial or nonfinancial statements and shall complete all materials honestly and without omission” (ASHA, 2016).

The U.S. Department of Education, the individual state’s department of education, and districts may impose their own requirements for documentation.

Americans With Disabilities Act of 1990 (ADA)

ADA 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 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 ADA Amendments Act of 2008 updated the law to clarify congressional intent. The provisions of ADA are closely aligned to Section 504.

Every Student Succeeds Act (ESSA)

ESSA, which became law in December 2015, replaced the No Child Left Behind Act. The goal of ESSA is to create a law focused on 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 [PDF].

FERPA

FERPA 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.

There is a difference between allowing access to records and providing copies under FERPA. FERPA does not require copies of documents to 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).

IDEA (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. The determination of eligibility and types of services required is completed following specific procedures for a multidisciplinary assessment and through an IEP process. Students become members of a protected class in the United States when they are determined to have a disability under IDEA (2004). 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 law, each state can create additional rules that interpret the law for their particular state. Although state rules cannot require less than what is required by the federal government, they can require more. Therefore, it is important for clinicians to understand their state’s regulations for special education.

HIPAA (1996)

HIPAA (1996) 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 often seek information from health care providers or bill Medicaid, there is periodic confusion and resulting questions about which HIPAA requirements apply in school settings.

In most cases, HIPAA privacy rules do not apply to public schools because the school is either not a HIPAA-covered entity or 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 C.F.R. 99.30) at the time the records are sent to Medicaid, and then that transaction falls under HIPAA.

A private school that does not receive 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. The intent of both HIPAA and FERPA is confidentiality.

Section 504 of the Rehabilitation Act of 1973

Section 504 of the Rehabilitation Act of 1973 has a broader definition of disability than IDEA (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 the chart from the Understood Program at the National Center for Learning Disabilities The Difference Between IEPs and 504 Plans.

Resources

ASHA Resources

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

References

American Speech-Language-Hearing Association. (2010). Issues in ethics: Responsibilities of individuals who mentor clinical fellows in speech-language pathology [Ethics]. https://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]. https://www.asha.org/policy/

Americans With Disabilities Act of 1990, Pub. L. No. 101-336, 104 Stat. 328 (1991).

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).

Hoover, J. J., Erickson, J. R., Patton, J. R., Sacco, D. M., & Tran, L. M. (2019). Examining IEPs of English learners with learning disabilities for cultural and linguistic responsiveness. Learning Disabilities Research & Practice, 34 (1), 14–22. https://doi.org/10.1111/ldrp.12183

Individuals with Disabilities Education Act of 2004, 20 U.S.C. § 1400 (2004).

Moore, B. J. (2010a). Documentation for SLPs and audiologists in schools [Audio program]. American Speech-Language-Hearing Association.

Moore, B. J. (2010b). If it’s not documented, it didn’t happen. Perspectives on Administration and Supervision, 20 (3), 106–110.

Moore, B. J. (2013). Documentation issues. In R. Lubinski & M. Hudson (Eds.), Professional issues in speech-language pathology and audiology (4th ed.; pp. 420–443). Delmar.

Moore, B. J., & Montgomery, J. K. (2008). Making a difference for America’s children: Speech-language pathologists in public schools (2nd ed.). Pro-Ed.

Esparza Brown, J., & Turner, M. (2016). Analyzing linguistically appropriate IEP goals in dual language programs [Conference session]. 2016 Dual Language Conference: Making Connections Between Policy and Practice, Framingham, MA, United States.

Newport-Mesa Unified School District v. State of California Department of Education, 371 F. Supp. 2d 1170 (2005).

Office of English Language Acquisition. (2016). Tools and resources for addressing English learners with disabilities . https://www2.ed.gov/about/offices/list/oela/english-learner-toolkit/chap6.pdf [PDF]

Office of Special Education Programs. (2021). OSEP Policy Letter 21-03 . https://sites.ed.gov/idea/files/policy-letter-11-15-2021-to-boals.pdf [PDF]

Rehabilitation Act of 1973, Section 504, Pub. L. No. 93-112, 87 Stat. 394 (Sept. 26, 1973), codified at 29 U.S.C. § 701.

U.S. Department of Education. (2016). Non-regulatory guidance: English learners and Title III of the Elementary and Secondary Education Act (ESEA), as amended by the Every Student Succeeds Act (ESSA) . https://www2.ed.gov/policy/elsec/leg/essa/essatitleiiiguidenglishlearners92016.pdf [PDF]

U.S. Department of Justice & U.S. Department of Education. (n.d.). Ensuring English learner students can participate meaningfully and equally in educational programs [Fact sheet]. https://www2.ed.gov/about/offices/list/ocr/docs/dcl-factsheet-el-students-201501.pdf [PDF]

About This Content

Acknowledgments

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 Documentation in Schools page:

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Documentation in schools [Practice Portal]. https://www.asha.org/Practice-Portal/Professional-Issues/Documentation-in-Schools/

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.