Determining Appropriate Services – Clinical Documentation Guidelines

Appropriate services offered to students are determined with the goal of reducing the impact of the impairment(s) in order to provide equal access to the learning environment at Marymount.  All accommodations need to be directly related to the disability and its impact on the student.  In order to establish an existing disability, students are requested to submit their SAS Registration packet with appropriate clinical documentation from their licensed provider.

The appropriate clinical documentation format should meet the following criteria:

  • Be typed or printed on official letterhead and be signed by the appropriate qualified licensed professionals who completed the evaluation and made the diagnosis
    • Appropriate qualified licensed professionals should include information about license or certification and/or area of specialization.
  • Include any completed educational, developmental and medical history relevant to the student’s disability for which testing accommodations are being requested.
  • Include a list of all test instruments used in the to complete the evaluation and relevant subtest scores used to document the stated disability; all test instruments must have adult norms.
    • This requirement doesn’t apply to physical or sensory disabilities of a permanent or unchanging nature.

The appropriate clinical documentation can come in, but is not limited to the following formats:

  • Primary Clinical Documentation Examples
    • Educational or Psychological Assessments/Evaluations: Commonly used in educational settings to understand an individual’s strengths and weaknesses, diagnose learning disabilities or other conditions, and inform the development of appropriate educational interventions and accommodations.
    • Medical Records: These records provide information about a student’s diagnosis, treatment history, and the healthcare provider’s assessment of a student’s condition. They can include reports from doctors, specialists, or therapists.
    • Diagnostic Reports/Assessments: Reports from medical tests or evaluations that confirm a student’s diagnosis, such as MRI scans, X-rays, blood tests, or psychological assessments.
    • Letters from Licensed Healthcare Professionals: Letters or statements from qualified healthcare professionals, such as physicians, psychologists, or counselors, that outline the nature and impact of a student’s condition on their ability to participate in academic activities.
  • Supplemental Documentation Examples
    • IEPs and/or 504 Plans: High school, middle school and grade school education plans, such as IEPs and 504 Plans, are customized plans tailored to meet the unique learning needs and challenges of a particular student.  These cannot be “transferred” into the post secondary academic setting as these plans are developed under different regulations following IDEA and Section 504 requirements to ensure students are successful relative to their abilities in the K-12 system. At the collegiate level, including Marymount, we develop accommodations for our students by following the ADA and Section 504 (and the way disabilities under the law are defined).
    • Post Secondary Accommodations Sheet: Previous post secondary institutions accommodation sheets are able to be reviewed to see what was previously approved by another institution; however, Marymount would still require new or existing clinical documentation that was used to create the previous institutions accommodation sheet.

The appropriate clinical documentation should include, but is not limited to having the following information from the appropriate qualified licensed professionals:

  • Diagnosis 
    • Official clinical name of the student’s physical and/or mental impairment(s).
  • Severity Level 
    • Degree or extent to which a physical and/or mental health condition(s) impacts an student’s well-being, functioning, and overall health in a post secondary academic setting.  
    • Severity levels can include but are not limited to mild, moderate, severe and profound/critical.  
  • Frequency and Duration 
    • How often the specific physical or mental health condition(s) affect the student’s well-being, functioning, and overall health in a post secondary academic setting.
    • Frequency is typically expressed, but not limited to, as a numerical value or  percentage to measure how often symptoms may occur during a certain time frame specific to a post secondary academic setting.
  • Impacted Areas in a Post Secondary Academic Setting
    • Description of how the student’s impairment(s) substantially limit(s) one or more major life activities (such as hearing, seeing, speaking, breathing, performing manual tasks, walking, caring for oneself, learning, or concentrating) in the classroom, residential campus housing, university related activities and/or events or other settings in post secondary academic setting.

Marymount is not required to provide the exact accommodation or modification requested by the student or their treating/assessing professional.  For example, requests for accommodations that would alter essential course elements known as “core learning outcomes” may be deemed “unreasonable”.  If this occurs, there may be more feasible alternatives that would appropriately and fairly accommodate the student’s disability needs.