Documentation compliance
Turn session capture into reviewed clinical evidence.
The RBT captures the session. ABACare structures the note, attaches the source evidence, checks authorization context and routes it to the BCBA for review. A note that is unsigned or incomplete does not move downstream. It is surfaced with what is needed to fix it.
The reviewer sees the evidence under the note.
The chain is stopped at approval, waiting for a person. The note is read against the capture records it rests on. This is the product, on a fictional clinic.
Capture is one tap per trial.
The record the note and the claim later rest on is made in the session room.
The RBT captures on a tablet or dictates observations into the ABACare mobile interface. ABACare turns trials, ABC data, prompting levels, response counts and voice into a draft tied to the session record. The RBT reviews and submits.
No note is signed without clinical review.
- BCBA review gate. Every drafted note routes through approve, edit or return. The BCBA sees the note, the source transcript, the authorization context, the note diff and a parent-safe summary preview in one place.
- Audit-ready documentation. Each note links to its session, authorization, goals, reviewer and downstream claim readiness, with a timestamp trail from capture to sign-off.
- Late note detection. A note still in draft 48 hours after it was written becomes a named blocker on the owner and billing dashboards, oldest first. Past seven days it escalates to an error-severity documentation trigger on the note itself.
Most clinics treat the session note as after-the-fact paperwork. It is the first operational handoff: what happened, which goals moved, who reviewed it, what a parent may see, and whether the authorization and billing evidence is complete. One unsigned session can delay a family update, supervision follow-up, renewal evidence and a claim.
A worked example, one session from tap to signature.
An example with invented figures, to show how the chain works. It is not a customer result and not a prediction for your clinic.
Evidence
An RBT runs a session and records 24 trials by tap, plus two dictated observations. The records are tied to the session and the client's goals.
Rule
ABACare checks that the session matches an authorization and that the note has what it needs. A missing goal link is flagged.
Proposal
The note is drafted from the capture records and marked as a draft. It is not signed.
Approval
The BCBA reads the note beside the recorded frequencies, edits one sentence and signs. The signature is tied to a hash of what was signed.
Action
The note counts as signed, so the signed-note check passes for the claim and the parent-safe summary can be reviewed for release.
Audit
If the note had stayed in draft, it would have become a blocker on the owner and billing dashboards at 48 hours.
What ABACare does today, and what it does not.
- Does: draft the note from capture records and hold it for BCBA review.
- Does: flag missing evidence before sign-off and surface late notes by age.
- Does not: sign a clinical note, ever. A clinician signs, and the signature is tied to what was signed.
- Does not: decide medical necessity, or stand in for clinical supervision.
Questions about ABA session notes.
- Who signs the session note?
- A clinician. ABACare drafts the note and the BCBA approves, edits or returns it. The signature is tied to a hash of what was signed, so an edit after signing is caught.
- When does a late note become a problem?
- A note still in draft 48 hours after it was written becomes a named blocker on the owner and billing dashboards. After seven days it raises an error-severity documentation trigger on the note.
- What happens to a claim if the note is unsigned?
- The claim is held. The signed-note check is one of the seven pre-claim checks, and a failing check keeps the claim in the review queue with the reason named.
- Can I try this without real client data?
- Yes. The live demo is a fictional clinic: no password and no PHI. Start free opens a sandbox on synthetic data. Self-serve real client data requires a signed BAA and verified active Type-2 organization NPI; production use also follows a separate readiness approval.