Documentation Guidelines for Head Injury/Traumatic Brain Injury

Head injury and traumatic brain injury are considered medical or clinical diagnoses. Individuals qualified to render a diagnosis for these disorders are practitioners who have been trained in the assessment of head injury or traumatic brain injury. Recommended practitioners might include:

1. Medical physicians
2. Licensed clinical or rehabilitation psychologists
3. Neurologists
4. Neuropsychologists
5. Psychiatrists

Documentation must be typed and current within the last three years. Although some individuals have longstanding or permanent diagnoses, because of the changing manifestations of traumatic brain injuries, it is essential for those individuals to provide recent and appropriate documentation from a qualified evaluator. Documentation should be provided on the official letterhead of the doctor, institution, and/or agency making the diagnosis. Documentation should be comprehensive and should include:

1. The diagnostician’s name, title, license/certification credentials, phone/fax number, address, and signature and the date(s) of treatment
2. A clear diagnostic statement of the head injury or traumatic brain injury
3. A description of current functional limitations. In clear, direct language, the report must identify the functional impact or limitations of the disability on learning or another major life activity. It should demonstrate whether and how a major life activity is substantially limited by providing a clear sense of the severity, frequency and pervasiveness of the conditions and how it impacts academic performance.
4. A summary of cognitive and achievement measures used and the evaluation results, including the standardized scores, used to make the diagnosis
5. A summary of present residual symptoms that meet the criteria for diagnosis
6. Medical information relating to the student's needs
7. The impact of medication on the student's ability to meet the demands of the postsecondary environment
8. Suggestions of reasonable accommodations that might be appropriate at the postsecondary level. These recommendations should be based on significant functional limitations and should be supported by the diagnosis.