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Documentation Guidelines for Head/Traumatic Brain Injuries

Head Injury or Traumatic Brain Injury is 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 may include physicians, neurologists licensed clinical psychologists, school psychologists, neuropsychologists and psychiatrists.

Documentation must include:

  • A clear statement of the head injury or traumatic brain injury and the probable site of lesion.
  • A summary of cognitive and achievement measures used and evaluation results including standardized scores or percentiles used to make the diagnosis.
  • A summary of present residual symptoms that meet the criteria for diagnosis.
  • Medical information relating to student’s needs to include the impact of medication on the student’s ability to meet the demands of the postsecondary environment.
  • Suggestions of reasonable accommodations that might be appropriate at the postsecondary level are encouraged. These recommendations should be supported by the diagnosis.