Smart Documentation

Guided documentation designed for speed, consistency, and quality.

How is the information captured?

Behind the scenes..

4. Group Goals

By setting:

  • Soft Gym

  • Outside

  • Social Skills

  • Rec Room

  • Daily Living

  • Lunch

  • Structured Game

  • Other

Include prompt levels and any notable participation.

5. Behavior

If ABC occurred:

  • Antecedent

  • Behavior

  • Frequency/duration

  • Interventions

  • Outcome

If only tracked frequencies:

  • List frequencies only

6. Additional Interventions

Examples:

  • Social story

  • Visual schedule

  • Response blocking

  • Coping strategies

  • Fluency

  • Response cost

  • Power cards

  • Pairing

1. Session Status

  • Smooth

  • Moderate

  • Challenging

2. DTT Programs

Include:

  • Exact program names

  • Exact scores/prompts

  • BL, Gen 1, Gen 2, RR, NE, maintenance, TS, etc.

  • Any spontaneous generalization

  • Any reruns or additional targets

3. Prompting / Session Flow

  • Prompting level

  • Redirections

  • Attention issues

  • PT response

7. Billing Structure

  • Direct (97153)

  • Dyad (97154)

  • Mixed day

  • Full day dyad

For dyads:

  • Main Client

  • Client A

  • Client B

  • Client C

  • Include times

8. Additional Support

  • BCBA

  • Lead support

  • Additional staff

  • Coverage changes

9. Reinforcement

  • DRA

  • VR schedule

  • Token economy

  • Edibles

  • Other reinforcement

10. Safety / Reporting

  • Injuries

  • SIB

  • Aggression

  • Elopement

  • Incident reports

  • Caregiver communication

Finalized note will utilize:

  • Hybrid Clinical Narrative System

  • BCBA/audit-defensible language

  • Exact DTT scores

  • SG/mastery interpretation

  • ABC formatting

  • Individualized dyad notes

  • Proper 97153/97154 separation

  • Space-conscious formatting for your center

  • TS interpreted as Teaching Strategy

  • Exact prompt scores treated as final data.

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— FIRST/then