Documentation Guidelines for LD
Learning Disability
Appropriate documentation should be on letterhead, typed, dated,
signed, recent (within 3 years) and consist of a comprehensive
assessment battery that includes:
- A diagnostic interview - a description of the presenting
problem(s), academic, medical, psychosocial and family histories.
- Assessment of aptitude and measures of academic achievement and information processing with test scores -
- Aptitude: A complete intellectual assessment with all subtests and standard scores reported.
- Academic Achievement: A comprehensive academic achievement battery is essential with all subtests and standard scores reported for those subtests administered. The battery should include current levels of academic functioning in relevant areas such as reading (decoding and comprehension), mathematics, and oral and/or written language.
- Information Processing: Specific areas of information processing (e.g. short/long-term memory, sequential memory, auditory and visual perception/processing, processing speed, executive functioning and motor ability) should be addressed.
- A specific diagnosis: The evaluator should make a specific DSM (Diagnostic and Statistical Manual of Mental Disorders) diagnosis if indicated by the testing data. Non specific diagnoses, such as 'individual learning styles,' 'learning differences,' 'academic problems' and 'test difficulty or anxiety' in and of themselves do not constitute a learning disability.
- Test Scores: Standard scores and/or percentiles should be provided for all normed measures. The particular profile of the student's strengths and weaknesses must be shown to relate to functional limitations that my necessitate accommodations.
- A clinical summary that contains recommendations for specific accommodations should include -
- Indication of how patterns in the student's cognitive ability, achievement and information processing reflect the presence of a learning disability.
- Indication of the substantial limitation to learning presented by the learning disability and the degree to which it affects the individual in the learning context for which accommodations are being requested.
- Indication of any record of prior accommodations or auxiliary aids, including any information about specific conditions under which the accommodations were used (e.g. standardized testing, final exams).
- Specific recommendations for accommodations, including an explanation as to why each accommodation is recommended.
- The name, title, and professional credentials of the evaluator.
Note: An IEP (Individualized Education Program) or a 504 Plan are not considered sufficient for the purpose of diagnosis.
