Session notes

An ABA session note is a daily note written for the session's visit. NeatPractice adds a note template for each kind of session:

Each ABA code points at its template, so the visit checks warn when a note is written on a template the code is not documented on. Every template has a session narrative, the learner's response and the plan for the next session; the code-specific ones add their own questions. Note any change in the learner's home, school, routine or staff under Environmental changes: the month's monthly summary lists each one by date.

Care continuity#

At the top, Care continuity shows where the team left off: the learner's last session in ABA (when, with whom, its codes, whether its note is signed, the programs and behaviors it recorded and its data results) and the next appointment booked. Read it before you write, so today's note follows on from the last one.

Session details#

Below the template, the Session details section records what the session covered, picked from the learner's plan. Your clinic's pick lists, such as antecedents grouped by function, appear in the note's own Pick lists section:

• Programs worked, Behaviors addressed and Interventions used list the learner's own programs and interventions.
• People present and Reinforcers, one per line. The reinforcer help lists the learner's preferred items, or your clinic's default reinforcers while the learner has none (see ABA settings).
• For each program or behavior you pick, a row asks its Main focus, which starts from the program's measure (a frequency behavior starts at Reduce frequency, a discrete trial program at Increase accuracy). A program also asks which of its Teaching procedures you used; a behavior asks what it was Evidenced by.

Click Save Details to keep them. They print with the signed note. Until you do, the footer shows Unsaved changes; closing, saving, signing, printing or inserting session data saves them first, and asks before closing if the save fails.

Session data#

Click Insert Session Data to add a summary of the data collected in the session: each target worked with its phase, measure and result, and behavior totals. When the learner withdrew assent during the session, the summary also notes each withdrawal time and whether assent was regained, and the signed note keeps them in an Assent table. The summary stays as it was inserted; click Refresh Data to insert it again. The programs it lists join Programs worked.

Codes and times#

When a session bills several codes, set each code's own Start and End inside the session under Codes and times and click Save Times. Each timed code's minutes and units follow its times. Codes cannot share minutes: if two codes overlap, NeatPractice names them and the times are not saved. Below the codes, a line shows how many of the session's minutes the codes cover, so you can see at a glance whether any time is left off a code or claimed twice. Changing the times on a visit the caregiver already signed clears that signature, as any change to the services does.

Remove a code that was not provided#

When a code was booked for the session but did not happen, such as a protocol modification when the analyst could not attend, click the trash icon next to it and confirm. The code comes off the visit and its units and the visit's status recalculate; the visit keeps a record of it. Only the code types your clinic allows in ABA settings can be removed (protocol modification, caregiver guidance and supervision to start with), and a session always keeps at least one code.

Before signing#

Besides the checks every note passes, an ABA session note must carry its medical necessity elements: start and end times, duration, codes and units, place of service, the rendering provider's credential, the people present, the targets worked (from the session data or the programs picked), the behaviors and interventions (when the learner has behavior programs), the learner's response and the plan for the next session. Your clinic chooses which ones, for every payer or per payer, in Note elements.

ABA codes need the provider's signature: add your signature image in your profile before signing. A technician's note then goes to the learner's case lead for review, and the caregiver signs the visit attestation once the session has ended.