12 Tips for Evaluators: Writing Quality Diagnostic Reports

These 12 tips may be useful as a final checklist before finalizing the disability documentation you are preparing for a client or patient.

  1. Documentation should be typed or printed on letterhead, dated, signed and be legible, including your name, title and professional credentials.
  2. Documentation should be recent. Documentation should be no more than five years old for LD, three years for ADHD and six months for psychiatric disabilities.
  3. Documentation should include the reason for referral.
  4. Documentation should include a listing of all the tests that were used to establish the disability and to support the accommodation requests. Evaluation measures selected for the assessment battery should be reliable, valid and age appropriate.
  5. Documentation should include developmental, educational and medical histories.
  6. The diagnostic report should have a clear statement of the disability.
  7. It is important that the report includes a "rule-out" statement.
  8. The report should provide appropriate measures of achievement.
  9. Test results should be clearly stated with all subtests noted.
  10. The clinical summary should recap the high points, rule out alternative explanations and summarize how the findings support any "substantial limitation" to a major life activity.
  11. Support for the requested accommodations must be tied to specific test results.
  12. Support for extended testing time should be specifically addressed by the evaluator.