What Documentation May Include

Disability-related documentation may be requested by schools, employers, healthcare providers, insurance companies, housing providers, government agencies, and other organizations to better understand how a health condition or disability may affect an individual's functioning.

Depending on the purpose of the request, documentation may address:

• A diagnosed or clinically identified condition

• Relevant symptoms or clinical concerns

• Functional limitations associated with the condition

• The activities or areas of functioning affected

• The nature, severity, frequency, or duration of relevant limitations

• The relationship between the condition and identified functional impact

• Clinically supported recommendations for accommodations or supports

• How a requested accommodation may address an identified functional limitation

The specific information needed depends on the purpose of the documentation and the requirements of the organization requesting it.

Documentation should generally focus on information relevant to the request rather than providing an individual's entire medical or mental health record. The EEOC notes that employers generally should request only documentation needed to establish the disability and the need for accommodation rather than unrelated medical information (EEOC, 2000).

Diagnosis Is Only One Part of the Picture

A diagnosis alone does not necessarily describe how an individual functions in a particular environment.

For disability documentation, understanding functional impact is often an important part of the clinical picture. Disability is understood in relation to functioning and participation, including the interaction between a person's health condition and their environment (World Health Organization [WHO], 2001).

For example, an individual may experience clinically significant difficulty with:

• Concentration or sustained attention

• Processing information

• Organization or prioritization

• Task initiation or completion

• Communication

• Emotional regulation

• Stress tolerance

• Attendance or consistency

• Transitions between tasks or environments

• Social or interpersonal functioning

• Sensory demands

• Stamina or endurance

• Activities of daily living

The relevant areas depend on the individual's circumstances and the purpose of the documentation.

The goal is not to assume that a diagnosis automatically results in a particular limitation. Rather, the clinical process considers how the individual's condition affects functioning in the context for which documentation is being requested.

From Functional Impact to Accommodation

Disability documentation is not simply about listing a diagnosis or checking a box on a form.

When relevant to the request, the clinical process may consider where an individual is experiencing difficulty and whether there are supports, modifications, or environmental changes that may help reduce the impact of those difficulties.

This may involve exploring:

• What is currently difficult

• How that difficulty is related to the individual's condition

• What settings the difficulties occur

• What circumstances increase or decrease the difficulty

• What strategies have already been tried

• What supports have been helpful

• What barriers remain

• What type of support may address the identified functional concern

• How the requested support addresses or reduces the identified barrier

• How the recommendation is supported by the available clinical information

• Any other relevant clinical considerations

This information can help create a clearer connection between an individual's clinical needs and a requested accommodation and helps ensure that documentation explains why a support may be helpful, rather than simply listing an accommodation that has been requested.