1. Child Outcomes Summary (COS) Process Training Module
Session 7:
Documenting the Child Outcomes Summary Rating
After reviewing earlier sessions, you now know how to reach a quality Child Outcomes Summary rating decision. In this session, we describe the evidence needed to document your rating. We discuss what we mean by documentation, why it is important, what it looks like, and questions you can ask to examine the quality of your own Child Outcomes Summary documentation.

2. What is Child Outcomes Summary (COS) documentation?
COS documentation is …
The evidence about the child’s functioning that led the team to the rating
Consistent with the rationale behind the rating
Commonly written in bulleted or brief narrative format.
The Child Outcomes Summary rating itself is a number that represents a summary snapshot of the child’s functioning in an outcome area. Documentation is the evidence that describes which features of the child’s functioning led the team to the rating. Documentation usually takes the form of a series of written bulleted items or a brief narrative paragraph.

3. Why is it important to document the child’s functioning?
Documentation
Verifies the accuracy of the rating
Supplies the evidence and rationale that led the team to arrive at its decision.
Documentation is important because it serves as a way to verify the accuracy of the Child Outcomes Summary rating. It shows that teams are applying the rating criteria appropriately. Documentation stands as a record of the team’s decision-making, showing the evidence and rationale for the selected rating.

4. Documentation as a Historical Record
Documentation can be used by …
A team member who could not be present when the rating was assigned
A new team member who wants to learn about the rationale for the earlier COS rating(s)
An administrator who wants to review the evidence that led the team to the rating for the child’s functioning.
Documentation can be used by current, as well as future or new, team members. A speech therapist, for example, could review the information if she could not be present at the meeting or a new provider who joins the team could review the documentation to learn about the aspects of the child’s functioning that led to the rating decision. An administrator may also appreciate this summary of the evidence that led the team to agree on a rating to describe the child’s functioning.

5. How Documentation Is Used to Improve the Quality of COS Ratings
Documentation provides insight into team decision-making.
Is the documentation consistent with the rating?
Is there evidence to show appropriate application of the rating criteria?
Systematic review of documentation can identify priorities for future training and technical assistance.
Documentation provides insight into team decision-making. States and local programs should be looking at documentation on a regular basis to identify if evidence is consistent with appropriate application of the Child Outcomes Summary rating criteria. By looking at documentation, for example, a reviewer can see if there is documentation and if it is consistent with the rating. If review of documentation shows errors in how teams are implementing the Child Outcomes Summary process, then the information can be used to plan additional training and technical assistance.

6. Effective Documentation
Can be in varied formats and locations
Regardless of format, always serves the same function:
Provides someone not present at the Child Outcomes Summary team meeting with an understanding of the rationale for the rating and the key evidence that led to it.
Now, let’s discuss the features of effective Child Outcomes Summary documentation and look at some examples.
Programs vary in exactly where the documentation goes and how the information is written. That is, some places use bulleted lists, others write short paragraphs, and others provide information in a table or another specific section of a form or data system.
Regardless of where and how the information appears, effective documentation will allow someone who was not present at the meeting to understand the team’s rationale for the rating and the key evidence considered that led to their decision.

7. Features of Effective Documentation
Provides evidence for the rating selected by…
Mentioning specific functional skills the child uses in everyday settings and situations and the consistency with which they are observed.
Describing the presence and absence of age-anchored skills (AE, IF, and F) that are consistent with the selected rating.
Focusing on the child’s current level of functioning rather than how much progress the child has made.
Identifying the assessment tool(s) that contributed information for the rating.
Let’s discuss the key features of effective documentation.
It is important that key skills are described with enough specificity for a reader to picture how the child uses her skills in everyday situations and to understand the consistency with which the child uses those skills.
Documentation should also include a description of the presence and absence of age-anchored skills at the levels that are important to the rationale for the rating. Remember, the critical distinctions across the rating criteria are the mix of skills the child has that are age-expected, immediate foundational, and foundational. The documentation needs to reflect the mix of skills in the rating selected, as applicable. For example, documentation for either a rating of 3 or 5 will provide evidence for different mixes of skills, whereas the documentation for a rating of 7 will note the child’s skills are all age-expected.
[Documentation, like the Child Outcomes Summary rating, should focus on the child’s current level of functioning, rather than how much progress a child has made in an outcome area.
Finally, documentation should name the assessment tool or tools that contributed information for the rating.

8. Connecting Documentation to Rating Criteria
The evidence needed to make the critical distinctions between ratings differs depending on the rating selected.
Remember, documentation provides the rationale for the rating.
Documentation must be consistent with the rating.
The questions on the decision tree can help guide what kinds of evidence to provide in the documentation for each rating.
The evidence recorded in documentation will differ depending on the rating that was assigned and provides the rationale for the selected rating. It is important to note that documentation must be consistent with the Child Outcomes Summary rating criteria. When using the decision tree, the questions underscore the critical distinctions between points on the rating scale.

9. Evidence needs to match the criteria for the rating.
If the rating is a 3, the documentation should …
Describe that the child shows mostly IF skills. This also shows the rating should not be a 2.
For example, if the rating on an outcome is a 3, the evidence in the documentation needs to be consistent with the criteria for a 3. Evidence showing the child has mostly IF skills in the outcome area also will show that the rating should not be a 2. In addition, the documentation should include a statement showing that the child is not yet using any age-expected skills. This confirms that the rating is not a 4 or higher.
Include a statement that the child has no AE skills. This further distinguishes the rating from a 4, 5, 6, or 7.

10. Evidence needs to match the criteria for the rating. (cont.)
If the rating is a 5, the documentation should …
Describe a mix of skills, with most being AE. This also shows the rating should not be a 4.
Here is another example. If the rating for an outcome is a 5, the documentation will provide evidence of a mix of age-expected and not age-expected skills. The evidence should make it clear that there are more age-expected than non-age-expected skills. This will distinguish the rating from a 4. The evidence of non-age-expected skills also distinguishes the rating from a 6 or a 7.
Show that some skills are not at an age-expected level. This further distinguishes the rating from a 6 or 7.

11. Example 1: Weak Documentation Leona, 43 Months, Outcome 2
Features of Effective Documentation
ABC Assessment Scores
Cognitive subdomain standard score 84
Communication subdomain standard score 78
Mentions specific functional skills the child uses in everyday settings and situations and the consistency with which they are observed.
Describes the presence and absence of age-anchored skills (AE, IF, and F) that are consistent with the selected rating.
Focuses on the child’s current level of functioning rather than how much progress the child has made.
Next, let’s take a look at some examples of documentation.
Here is an example of some weak documentation. Take a moment to review the features of effective documentation and consider why this documentation is weak.
In this example, the team simply recorded Leona’s assessment scores instead of providing any information about specific skills. It is good that the team included information from an assessment tool, but the evidence does not address the other features of effective documentation
Identifies the assessment tool(s) that contributed information for the rating.

12. Example 2: Weak Documentation Charles, 58 Months, Outcome 3
Features of Effective Documentation
See Early Intervention (EI) Record
Mentioning specific functional skills the child uses in everyday settings and situations and the consistency with which they are observed.
Describing the presence and absence of age-anchored skills (AE, IF, and F) that are consistent with the selected rating.
Focusing on the child’s current level of functioning rather than how much progress the child has made.
Here is another example of some weak documentation. Which features of effective documentation are missing from this example?
In this example, the team simply wrote a note saying to look at the child’s full Early Intervention record for evidence. Referring others to the child’s record gives no indication of why the rating was selected.
Identifying the assessment tool(s) that contributed information for the rating.

13. Example 3: Weak Documentation Jamie, 23 Months, Outcome 2
Features of Effective Documentation
Likes to do puzzles
Limited language
Some skills are age expected
Mentioning specific functional skills the child uses in everyday settings and situations and the consistency with which they are observed.
Describing the presence and absence of age-anchored skills (AE, IF, and F) that are consistent with the selected rating.
Focusing on the child’s current level of functioning rather than how much progress the child has made.
Here is another example of weak documentation. What is missing from this documentation that makes it weak?
Although this team does provide some information about the kinds of skills that were considered and some information about the age-anchoring of those skills, there is not enough detail on either of those points.
Identifying the assessment tool(s) that contributed information for the rating.

14. Example 4: Strong Documentation Jamie, 23 Months, Outcome 2
COS Rating : 4
Features of Effective Documentation
Mentioning specific functional skills the child uses in everyday settings and situations and the consistency with which they are observed.
Describing the presence and absence of age-anchored skills (AE, IF, and F) that are consistent with the selected rating.
Focusing on the child’s current level of functioning rather than how much progress the child has made.
Identifying the assessment tool(s) that contributed information for the rating.
Jamie shows age-expected skills primarily in the areas of receptive language and problem solving, such as:
Recognizes lots of objects; shows understanding of named objects by pointing to them from pictures (AE)
Easily solves problems, e.g., remembers where his parents hid treats (AE)
Most of Jaime’s other skills are a mix of immediate foundational and foundational (particularly in use of language), such as:
Follows two-step directions, e.g., gets shoes and brings them to his mom when he is getting ready to leave the house (IF)
Points to items to draw others’ attention to things that he wants but does this inconsistently (IF)
Uses gestures to communicate when he is calm or at home, but in other settings/situation, he cries, screams, or grunts (F)
Uses some single words (e.g., mama, no); showed an 11-month delay on Expressive Language subdomain of the ABC Assessment (F)
Now take a moment to read an example of strong documentation presented in bullet format.
You can see that a few skills are listed with enough specificity to age-anchor them. The team also includes brief information about how commonly these skills are observed.
This documentation supports a rating of 4. It shows that the team found some age-expected functioning, but the mix is such that most of the child’s skills are immediate foundational or foundational. There are specific enough examples that an external reviewer can confirm the rating.

15. Example 4: Strong Documentation Jamie, 23 Months, Outcome 2
COS Rating : 4
Jamie shows some age-expected skills primarily in the areas of problem solving and receptive language. For example, his father reports that Jaime has a strong memory and will regularly remember where his parents hid treats. Jaime also recognizes lots of objects, showing his understanding of named objects by pointing to them from pictures or picking them out of a group. Most of Jamie’s skills in the outcome area are at the immediate foundational and foundational levels. Examples of immediate foundational skills including Jamie’s ability to follow recurring two-step directions (e.g., getting his shoes and bringing them to his mom when he is getting ready to leave the house) and pointing to draw others’ attention to things that he wants. Skills at the foundational level include his inconsistent use of gestures and use of a few single words. He more often cries, screams, or grunts to communicate his curiosity or interest in things to others.
As noted earlier, effective documentation can be written as a brief paragraph instead of with bullets. Here’s the same documentation for the previous child, Jamie, but in paragraph format.

16. Documentation Takes Practice
Documenting evidence for the team’s rating decision is an essential part of a high-quality Child Outcomes Summary process. Writing good documentation takes practice. In the Just for Me activity for this session, you will have the opportunity to develop documentation for Kim, the child you met in Session 5. We encourage you to complete the activity and reflect on how you can incorporate key features of effective documentation into your practice.