ABA Records – Medical & Health ABA Records Documentation 101
Discover ABA records documentation best practices and how to appropriately manage medical and health ABA records.
ABA records must be established and maintained in a professional manner. Specific requirements may vary by state and funding source. Regardless of local mandates, it’s always best to keep the integrity and accuracy of your ABA records in tip-top shape. In this article, you will learn the following:
What are ABA Records?
ABA records are documents held in a client’s medical record. These records are vital for both clients and providers. Great care must be taken in establishing practices surrounding the creation and maintenance of records.
ABA records include the following:
- Personal identifying information, such as name, date of birth, social security number, phone number, and caregiver information
- Insurance information, including the name, member and group ID, and a copy of the insurance card
- Medical and behavioral health background, including a health history from perinatal onward, previous and current therapies, diagnostic evaluations, medications, and allergies
- Consent forms such as release of information documents, payment policies, and service agreements
- Client data such as assessment results, behavior data, program data, and graphs
- Plan of care/treatment plans
- Behavior Intervention Plans
- Daily session notes
- Progress summaries
- Discharge documentation, including discharge plans and summaries
ABA Records Documentation Best Practices
Because documentation requirements vary based on the payor, the general best practice is to create documentation procedures that fulfill the requirements of your strictest payor and use those across the board.
Medical records must be legible and easy to understand by anyone with authorization to read your documentation. Electronic data systems eliminate the challenges that arise with illegible handwritten documentation.
Readability extends beyond legibility. Identifying who will be reading the documentation and writing in a manner that the audience will understand is vital. This is particularly true of documentation that clients and caregivers will read. While maintaining the accuracy of the information, avoid excessive jargon or language that is too technical.
Medical documents must be factually truthful. Objectivity is essential in all medical records. Avoid subjective language, assumptions, or anything else that cannot be objectively verified. If you are recording client or caregiver reports, make it clear that these are subjective reports and not your own observations.
Accuracy is crucial in medical documentation. Before finalizing any medical record or documentation, double-check for accuracy. Even a minor typo can cause challenges. For example, a behavior technician writes that there were 2 occurrences of self-injurious behaviors that session, but he missed the zero, intending to type 20. Thoroughly review documentation to identify and remedy typographical errors.
ABA records should be written clearly and concisely. Do not leave anything open-ended or open to interpretation. Funders are known to thoroughly evaluate medical records to ensure medical necessity is demonstrated. Clarity of records helps to avoid any misunderstanding, reducing the risk of returns and denials.
Up to Date
Medical documentation must be kept up to date. Regularly review your records to ensure that personal information, diagnoses, medications, and other vital information are current.
Required ABA Records Details
The following documentation must be included in each client’s medical record.
- Date of Birth
- Home address
- Contact information
- School / Employer
- Marital or legal status
- Emergency contact information
- Active diagnoses
- List of current medications
Other details may be necessary based on the location where services are rendered and the funding source’s requirements. Consult your local regulations and funding source to determine whether additional information is necessary for your documentation.
Proper ABA Medical Records Management
Managing medical records that meet funder requirements, HIPAA regulations, and any other state or local laws are vital for any organization.
Complete Internal Audits
External audits can create significant stress and financial burden on providers. It is necessary to ensure you are ready for external audits when they arise. ABA providers should conduct routine internal record audits on medical documentation. With CentralReach’s electronic medical records, internal audits can easily become a regular and ongoing process.
Automate Processes Where Possible
Automating ABA records is an excellent way to streamline your workflow and save time. The best way to do this is to use a web-based software platform that allows you to store and manage all of your ABA records in one place. This will help you to track and manage data quickly and easily.
Provide On-going Training
Providing ongoing training in creating and maintaining medical records is crucial for ensuring accuracy and compliance with industry regulations. All team members, both clinical and administrative employees, should receive training on an ongoing basis in medical record documentation, maintenance, and safeguarding.
ABA Health & Medical Records FAQ
Applied Behavior Analysis (ABA) is a type of treatment used primarily with children with autism and other neurodiversity. ABA therapists apply principles of behavior to teach people new skills and modify behaviors that interfere with the quality of life. ABA therapy is research supported and is considered an evidence-based practice.
For Medicaid providers, the Centers for Medicare and Medicaid Services require providers to hold on to medical documents for a minimum of seven years from the date of services.
Each state has its own laws regarding minimum retention periods for medical records. It is important to confirm the laws in your jurisdiction. Many states hold the seven-year requirement. However, some states hold different requirements. For example, New York requires medical records to be maintained for a minimum of six years or until the patient is 22 years of age, whichever is longer.
ABA is most often used to support children with autism. The majority of practitioners in the field, roughly 70%, work with the autism population. However, the principles of behavior extend beyond children with autism; therefore, ABA can be successfully applied to many different populations.
In addition to autism spectrum disorder, ABA can also be used for the following challenges:
- Substance abuse
- Eating disorders
- Impairment following brain injury
- Anger management
- Borderline personality disorder
- Anxiety disorders
ABA can even be used within organizations to assess and improve workplace practices, including employee satisfaction and retention, training of staff, improving quality standards, and more.
Session notes are a key component of a client’s medical record. Session notes should be completed at the end of each session or as soon after a session as feasible. Our ability to remember events is not as strong as we might like to believe they are. If you’re writing your session note days after the session concluded, it is highly likely that you will miss important information or add incorrect information that perhaps was a component of another session.
Session notes must be written objectively, without emotion or assumptions. This is a medical document and should be treated as such.
Session notes should include:
- Client’s full name or a unique identifier
- Session date
- Session start time and end time
- The total duration of the session
- Location of service
- Rendering provider and credential
- Type of service provided
- Other individuals present
- Strategies used
- Subjective reports from caregivers or client, if applicable
- Client’s response to treatment
- Summary of the session and client progress
- Barriers to client progress
- Provider signature
Again, some payors may require additional information, so be sure to confirm with your contracted funding sources. It is best practice to use a template that covers the requirements for your strictest payors.
- ABOUT BEHAVIOR ANALYSIS – Behavior Analyst Certification Board. (2017). Bacb.com. https://www.bacb.com/about-behavior-analysis/
- “Medical Record Maintenance & Access Requirements.” Cms.gov, Apr. 2022, https://www.cms.gov/files/document/mln4840534-medical-record-maintenance-and-access-requirements.pdf.
- Documenting the provision of services. NYS Mental Health Practitioners:Practice Guidelines:Guideline 4. (n.d.). Retrieved December 31, 2022, from https://www.op.nysed.gov/professions/mental-health-practitioners/professional-practice/documenting-the-provision-of-services