Traumatic Brain Injury

Documentation Guidelines for Traumatic Brain Injury.

Photo of a human brain.

Assessment Providers

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: medical physicians, licensed clinical or rehabilitation psychologists, neurologists, neuropsychologists, and psychiatrists.

Assessment Documentation

Documentation must be typed and current within the last 3 years. Although some individuals have long standing 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:

  • The diagnostician’s name, title, license/certification credentials, phone/fax number, address, signature, and date(s) of treatment
  • A clear diagnostic statement of the head injury or traumatic brain injury
  • 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 other 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.
  • A summary of cognitive and achievement measures and evaluation results used to make the diagnosis, including standardized scores
  • A summary of present residual symptoms which meet the criteria for diagnosis
  • Medical information relating to the student's needs
  • 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. These recommendations should be based on significant functional limitations and should be supported by the diagnosis. Further assessment by an appropriate professional may be required if co-existing learning disabilities or other disabling conditions are indicated.