Documentation Doozies: Addressing Common Concerns in School

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Barbara J. Moore, Ed.D., CCC-SDirector, Special Education, San Marcos USDASHA Vice President, Planning, 2011 - 2013

Disclosure: Barbara J. Moore

I do have publications on issues related to school services, for which I do receive a royalty, and that may discuss some of the issues reviewed in this presentation. Some of the articles and information I have produced on the topic of documentation were commissioned for a fee; however, I receive no additional compensation for those publications. I am receiving an honorarium for this presentation.

AGENDA

• Documentation Basics for School Settings• 5 Documentation Doozies:

1. Due Process, Attorneys and Courts2. Reports3. Present Levels of Performance, Goals, Service

Delivery4. Request for Records, including protocols5. Email and Personal Records

• Q & A

Why is this such a Hot Topic???Because it’s CONFUSING!

• CONFUSION: Overwhelming mountain of paperwork and variations in expectations for paperwork

• CONFUSION: Difference between what’s documented and what’s done

• THREATS of due process• High levels of professionalism in our field• High level of expectation of our position• More……..??????

Purpose of Documentation

• Through documentation we:– Prove compliance– Design plans– Present rationale – Justify recommendations – Submit financial remuneration requests

(Moore, 2012)

ASHA Code of Ethics (2010)Principle I, Rule M

• “Individuals shall adequately maintain and appropriately secure records of professional services rendered, research and scholarly activities conducted, and products dispensed, and they shall allow access to these records only when authorized or when required by law”(p. 2)

General Principles of Documentation

• Requirements for documentation set forth by laws and regulations, as well as by the professional expectations of our field

• Hint: use formal writing style, conventions of formal written language, abbreviations as appropriate

• Documentation:– Drives the action of the reader– Reflects on the writer (you) and your program(Moore, 2012)

WARNING!

• “If the record is not clear, concise, and comprehensive, then the therapeutic process is at risk” Hapner, 2008, p. 33

Levels of Laws and Regulations

• Federal– Public Law (IDEA 2004)– Code of Federal Regulations

• State– State Law– Education Code

• District– School Board Policy– Administrative Regulations

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The BIG Laws!

• Compass for Protecting Individual Rights– IDEA– Rehabilitation Act of 1973/504 – FERPA– NCLB– HIPAA– ADA

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Focus on IDEA• Pre-referral

– Didn’t used to worry about this before IDEA 2004 and the advent of RTI

– However, it’s always been required to demonstrate that general education cannot meet the needs of a referred student

– Now we are more systematic – Now, SLPs are involved in the

pre-referral interventions– Can be CONFUSING!

• IDEA Eligible– Clearer in terms of the expectations,

especially as it relates to timelines, areas of the IEP, etc.

– BUT still many variations in WHAT is put into and onto IEPs and reports

– What about other agreements, etc.– Blending of general education

requirements into IDEA is CONFUSING

– Multi-disciplinary team develops IEP and sometimes there is CONFUSION, or a different style

– Even when we know what to do, sometimes it’s hard to get it done!

DOCUMENTATION 101

• Electronic IEPs help in terms of completing the requirements of IDEA

• Documentation should “thread the needle” – tell the story of the student’s path

• Expectation in all settings; not just schools.

DOCUMENTATION 101

• KEY: Documenting process• KEY: Documenting rationale• KEY: Documenting who is doing what and why• KEY: Documenting parental input into the IEP• KEY: Documentation consistency in your

organization• KEY: Documentation terminology (e.g. using

appropriate terminology)• KEY: Doing what is documented!

DOCUMENTATION DOOZIE #1:DUE PROCESS, ATTORNEYS AND COURTS

Substantive vs. Procedural Violations • Substantive Violations– Denial of FAPE– Failure to Assess– Based on what you have done, has the student received

educational benefit?– Have we failed to do something that we should have done?

• Procedural Violations– Failure to comply with IDEA-mandated procedures

• Timelines, notice, meeting, documentation, etc.

– Does procedural violation rise to the level of a denial of FAPE to the student, or impede the parents’ right to meaningfully participate in the IEP process?

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DOCUMENTATION DOOZIE #1:DUE PROCESS, ATTORNEYS AND COURTS

• Think about what the process of due process is about. Can you provide documentation to prove the following? – > Can you show that you have provided a FAPE? – > Can you show that the way you handled the case

was consistent with legal requirements? – > Can you show that the way you handled the case

was consistent with standards of the field?– > Can you show that you have the credentials to do

what you do?

DOCUMENTATION DOOZIE #1:DUE PROCESS, ATTORNEYS AND COURTS

• Process for Due Process: A Quick Review– Filing– Resolution Session, Mediation, Hearing

• Office of Administrative Hearing (OAH)– http://www.dgs.ca.gov/oah/Home.aspx

• What are they really looking for?– Sample Cases

Documentation Doozie #2: Reports

• S/L and audiology reports done as part of a Multi-disciplinary assessment. Need to connect to other disciplines.

• COMMON REPORT WRITING ERROR: Write up only standardized testing results; Failure to connect to classroom performance or results of other assessors

Assessment and Evaluation Reports

• Be sure your report includes: – pertinent background, discussion of assessment results,

and explanation of choice of assessment instruments– documentation on suspected areas of need/ explanation of

student needs– justification for needed services– connection to other reports/assessments– information on interviews with parents and teachers

Report should be written in a professional manner, using professional terminology, but written so parents understand.

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Assessment and Evaluation Reports

• Be sure your report: – documents suspected areas of need– connects to other reports– documents current areas of concern– is written in a professional manner, using professional

terminology• Remember, your report reflects on both you and

your employer• Consider what it would be like to have to testify and

defend your report—can it stand on its own?19

Assessment Report Format

• Reason for Assessment• Background Information• Assessment/Testing:

– Standardized assessments or tests

– Observation in natural setting– Non-standardized

assessment or methods– Activities within natural

setting

• Behaviors observed during assessment

• Information on progress in academic or curricular areas

• Information on classroom assessments and statewide assessments

• Information from others (parents, teachers, aide, other MDAT members)

• Input from the student • Impressions• Summary/Conclusions• Recommendations

Assessment and Evaluation Reports

• Remember, your report reflects on both you and your employer

• Consider what it would be like to have to testify and defend your report—can it stand on its own?

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Documentation Doozie #3: Present Levels of Performance, Goals, Service Delivery

IEP Contents:

Practice Pointer

Remember!

• The IEP document should be comprehensive enough that if the student moved to a new district, the receiving school could implement the IEP based on the document itself.

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IEP Development:Present Levels Information for the IEP

• Information available from Student Data System– CST or CAPA– CELDT (including language classification)– CAHSEE

• Information available from Student Data System– Grades– Discipline– Health/attendance

• Information available from teachers– Benchmark testing– Work samples

• Input from parents and the student on concerns, desires, issues• Information from other related services providers (e.g., behavior specialist,

counseling, APE, etc.)24

IEP Requirements

PRACTICE POINTER for the Present Levels Page

•Leave no section blank on the present levels page. If the student is performing within normal limits (WNL) or at grade level, note it!

•Make statements in positive language.

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IEP Contents: Reporting Progress

• A description of the manner in which the progress of the pupil toward meeting the annual goals will be measured, and when periodic reports on the progress the pupil is making toward meeting the annual goals (e.g., through the use of quarterly or other periodic reports, concurrent with the issuance of report cards) will be provided.

• MUST report to parents on a periodic basis on progress toward goals!!

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Student Progress• Failure to make progress can be seen as a denial of FAPE. • Be sure to meet and account for any lack of student

progress.• If a student is not making progress, then need to

reconvene an IEP meeting and discuss.• If the student makes progress, document what that means

for the IEP (i.e., changing a goal or service; dropping a goal or service).

• Don’t let student progress go undocumented–one way or another!

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Therapy Notes

• Therapy notes are an educational record• Notes should document compliance with the

student’s IEP goals and service• Expect that these notes will be requested• Be objective in your documentation• Be complete and concise, but it is not necessary

to be lengthy• The old SOAP format is a good guide• Be sure to date and initial the notes

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Progress Notes: SOAP

• Subjective– write your opinion regarding relevant client behavior or

status in a brief statement

• Objective– record data collected for each task during the therapy session

• Assessment – interpret data for current session and compare to client’s

previous level of performance

• Plan– identify proposed therapy targets for the next session

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Documentation: Re-evaluation Reviews

• Need to re-establish if the student meets eligibility criteria and requires special education and related services

• Review of student’s progress over the past three years• Current review and documentation of student need• All IEP team members must complete a report—this report can be

multidisciplinary• Standardized measures may be used if needed, but are not required if the

team is completing an alternate or dynamic assessment• MUST have documentation of student’s areas of need, including all goal

areas, and current functioning/progress• Additionally required: all documentation necessary for the Annual (see

next slide!)

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Documentation: Annual Review

• What’s required: Documentation on ALL AREAS of NEED (e.g., goals)– Work samples– Portfolio of student progress– Student data information – Reports from classroom teachers– Description of how special

education is assisting the student31

Documentation: Annual Review

• What’s required: Documentation on ALL AREAS of NEED (e.g., goals)– Practice Hint: if the student is not demonstrating

an area of need in one of the sections indicated on the IEP, you need to document that too! Make statements about the student’s grade or age-appropriate functioning if this is the situation. Leave no space blank!

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IEP Development:

Goals and Benchmarks• Areas of need are identified through assessment for

initials/triennials• Must be a goal for each identified area of need• Document if student is no longer demonstrating an area of

need• Can’t have a service without a goal• Benchmarking (not a federal requirement; local policy)• MUST report to parents on progress toward goals (i.e., the

benchmark) for each reporting period (federal requirement) and review at IEPs (Note: be sure this gets documented for the permanent record)

• Academic Goals MUST be standards-based

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IEP Development:

Goal Information• Provide meaningful interpretation of data– build a bridge between the student’s performance

(i.e., the data, student classroom performance, student grades, observational information, input from other teachers and specialists) and the goals

• Need to compare to previous year’s goals and progress reports, and report on this

• The record needs to reflect that goals and progress have been reported to the parents at required intervals

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Goals Format

Who: the studentDoes What: observable behaviorWhen: by reporting dateGiven what: conditionsHow much: mastery or criteriaHow will it be measured: performance data

Goals

• Need to be standards-based• Need to be connected to the curriculum• Need to be measurable• OK to piggy-back on classroom goals• May have benchmarks – what’s your local

practice?• Progress must be reported to parents on a

regular basis – same as gen ed. teachers reports• Electronic systems often have drop-down menus

Speech and Language Goals

• IEP Guidance• http://www.asha.org/SLP/schools/IEPs/

– Consensus Points on Language Goals, Minneapolis Public Schools (F. Cirrin)

– http://www.asha.org/uploadedFiles/Consensus-Points-on-Language-Goals.pdf

– Writing Measurable Goals and Objectives (B. Conrad)– http://

www.asha.org/uploadedFiles/Writing-Measurable-Goals-and-Objectives.pdf

IEP meeting notes are

A MUST!!

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Failure to Follow the Process will Lead to Trouble EVERY TIME

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Service Delivery

• Service delivery models should be based on EBP of the field

• Be sure that the recommendation is based on the student need, and not the SLP convenience

• Consider current trends for intensity• See work of Gillam & Gillam re narrative

development, esp. as it relates to groups• Need to be able to connect rationale for service

delivery model

Documentation Doozie #4:Requests for Records, including Protocols

FERPAFamily Educational Rights and Privacy Act

• Three areas covered:– access to their education

records – an opportunity to seek to have

the records amended – some control over disclosure of

information from the records

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Record Retention Requirements• Mandatory Permanent Pupil Records:

– Required by state law, which usually includes identifying information about the pupil, when the student attended the schools in the district, and records of subjects taken, grades, immunization and date of graduation or exit.

• Mandatory Interim Pupil Records:– Held for a stipulated period of time, including health information, special

education information, language training records, progress reports, parental restrictions, parent/pupil challenges to records, parent authorizations/prohibitions for student participation in certain programs, results of standardized tests .

• Permitted Pupil Records:– Counselor/teacher rating scales; standardized tests older than 3 years;

routine discipline; behavioral reports; discipline notices; attendance records.

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Parent Requests for Records

• You know they have the right!

• Be careful about what’s in the file!

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Protocols

• These are part of the student records• Are Permitted Student Records• Can be requested• Be sure to copy all pages, including the blank

pages• HINT: When they ask for copies of the

protocols, they are going to check your scoring!

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Documentation Doozie #5:Email, Social Media and Personal Records

E-mail

• Is subject to subpoena• Be very, very careful!• If you don’t want the

child’s parent, your boss, your mother, or a judge reading it—then don’t send it!

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Social Media

• Hot, Hot, Hot Issue in Schools!!!• Generally have to sign a use agreement in the

district• Facebook, Twitter, etc. --- it’s exploding! • Avoid any reference to students or situations in

these formats…. They can be tracked!• Can lead to personnel problems if used

inappropriately• BE CAREFUL!!!!!

Personal Notes

•I say, “There’s no such thing!”•Here’s what the law says, according to Shorter

(2004): ▫Education records does not include records of instructional,

supervisory, and administrative personnel and ancillary educational personnel that are kept in the sole possession of the maker of the record, and are not accessible or revealed to any other person except a temporary substitute. Keep in mind, however, that once a personal note is shared, it becomes an “education record” (p. 21).

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Creating Legally Defensible Documentation

• Make sure the record can stand on its own• Can you “thread the needle” through the

documents, and tie everything together? • In due process hearings, when parents’

testimony, or their witness testimony, contradicts district, credence seems to be given to any documentation the district has to support their contention that “something took place” (i.e., logs, postal receipts, fax confirmations, etc.).

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One more thought….

• Don’t forget the importance of maintaining good relationships with parents.

• BUT don’t think this will prevent them from challenging what you do or what you’ve done!

Record Keeping and Documentation

• Yes, it’s true: if it’s not documented, it didn’t happen!

• Get yourself into the habit of documenting EVERYTHING… conversations with parents, phone calls, intervention, etc.

• Don’t rely on your memory… It will fail you and it won’t be the same as someone else’s (especially a parent’s)

• Lack of documentation is lethal. Poor documentation is worse.

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Documentation Resources• ASHA Website http://www.asha.org/SLP/Documentation-in-Schools/• Moore, B. J. (2010). Documentation for SLPs and Audiologists in Schools.

(Audio Program). Rockville, MD: ASHA. • Moore, B. (2013). Documentation issues in speech-language pathology and

audiology. In R. Lubinski & M. Hudson (Eds.), Professional Issues In Speech-Language Pathology and Audiology (4th Ed.) Clifton Park, NY: Cengage/Delmar Publishers.

• Moore, B. J. (2012, April 03). Five Common Documentation Questions—Answered. The ASHA Leader.

• Moore, B. (2010, October). If it's not documented, it didn't happen. ASHA Special Interest Division 11 (Administration and Supervision) Perspectives, 20, 106–112.

• Moore, B., & Montgomery, J. (2008). Making a difference for America's children: Speech-language pathologists in public schools (2nd Ed). Austin, TX: PRO-ED.

Questionsand Answers