The Documentation Request You Can't Quite Meet
You provide AT services to a 16-year-old, Jordan, with a traumatic brain injury, in a suburban district. You have completed three sessions focused on a mobile device with word prediction and speech output for writing. Your progress notes are brief but accurate. Jordan's case manager emails: 'The parents are threatening due process. I need you to write that Jordan has made significant progress with the device and that it's essential for his access to the curriculum. Can you send that today?' Your data show: Jordan independently uses word prediction on 3 of 8 writing tasks, requires verbal prompting on the rest, and has not yet generalized to classroom settings. You have not trialed any alternative. The device was parent-purchased.
1. What can and cannot go in your documentation, and why?
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You cannot write 'significant progress' or 'essential' as conclusions, because your data don't support either and because 'essential for access' is a determination with legal weight that requires evidence you don't have.
What you can document, accurately and usefully:
- Current performance: independent use on 3 of 8 tasks; verbal prompting needed on 5 of 8; no classroom generalization data yet.
- What was tried: device, word prediction, speech output; settings and prompting used.
- What is not yet known: generalization, comparison to alternatives, durability of gains.
- Recommendations: continued data collection, classroom trials, consideration of alternatives.
Why this matters: notes written to support a legal position rather than to record findings are both unethical and strategically risky - an accurate note that shows a trajectory and a plan often serves the family better than an inflated claim that collapses under cross-examination. 'Emerging progress with prompting' is honest and still supports continued services.
2. How do you respond to the case manager, and what do you offer instead?
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Respond promptly, warmly, and firmly. Acknowledge the pressure and the stakes for the family, then separate what you can attest to from what you can't: 'I can give you a precise picture of where Jordan is and a clear plan for the next four weeks - I can't characterize the device as essential when we haven't compared alternatives or seen classroom use, and a note that overstates it would be easy to challenge.'
Offer concrete substitutes:
- A rewritten progress summary with the actual data and a trend statement.
- A dated plan for classroom trials and an alternative comparison, so the team has a path to the stronger claim if the data support it.
- Willingness to attend the meeting or provide a written statement of current functioning.
Do not alter the record retroactively or let the request pressure you into conclusions. If the case manager pushes, restate the boundary once and offer to escalate to your supervisor rather than argue. Keep the email exchange in the file.