Managing the Complexities of ABA Session Notes: Leveraging AI for Session Note Audits

Ensuring documentation consistently meets payor requirements is an ongoing obstacle for many providers. There are several potential reasons for this.   

• Variability in Writing Quality–Session note quality can vary considerably based on the rendering provider’s writing abilities. Some RBTs and BCBAs struggle to clearly and objectively document their observations, learners’ responses to care, barriers to progress, and other pertinent information.  

• Time Constraints–There are often time constraints at play impacting the quality of session documentation. RBTs often have minimal time between sessions to complete notes, resulting in them rushing through.

• Payor Requirements Vary–Each payor has different requirements for session note documentation, making it challenging for providers to remember which funders require various components. Requirements can also change over time, which can be difficult for busy providers to keep up with.

• Lacking Knowledge of Payor Requirements–RBTs typically don’t receive training specific to documentation requirements per payor. Without prompts and safeguards in place, this often leads to notes that lack essential information. 

• Poor Legibility–Poor handwriting is a familiar challenge for organizations that complete hand-written session notes. An ability to read clinical notes is critical for substantiating services.  

• Retention of Session Information–Despite our best efforts to recall session information, our memory often fails us. If notes are not written at the end of the session, therapists may struggle to recall key details that must be accurately reported.