Clinical Documentation & Session Note Support

 Accurate documentation is essential for quality care, continuity, and compliance. The process of documentation involves creating a permanent record of services delivered — and in ABA, every detail matters.

I offer:

• Session note audits, monitoring, and template development

• Training on evaluating and improving documentation practices

• Support for writing effective transition and discharge criteria

• Guidance for creating medically necessary treatment plans

• Data aggregation to inform process improvements and ongoing staff training

Whether your team needs help with assessment reports, session notes, treatment planning, or discharge documentation, I’ll help you build clarity, consistency, and quality into every part of the clinical record. 

Medical Necessity

Medical necessity is all about proving that the services provided are not only clinically appropriate but also directly address the client’s needs. For ABA professionals, this means ensuring that every step—from assessment to treatment plan and session notes—reflects a clear connection between the client’s diagnosis and the services they’re receiving.
 

I specialize in helping ABA teams truly understand and apply medical necessity in their practice. This involves guiding them on how to align goals with the client’s needs, document progress effectively, and ensure their work meets payer expectations. With the right approach, organizations can provide clinically sound services that are also defensible and well-documented.

Compliance Systems

"If you think that compliance is expensive: try non-compliance."

This quote from former US Deputy Attorney General Paul McNulty provides a picture of the contrast between the costs associated with making sure an organization's systems and processes are aligned with regulatory, legal, and ethical requirements  and the consequences of not having any protections in place. No matter the size, any organization providing ABA services should prioritize establishing an internal compliance program to help safeguard service delivery and the longevity of care. Reach out how see how I can help you establish or evaluate your systems of clinical compliance. 

Clinical Due Dliligence

I assist companies, including private equity firms, with clinical due diligence during the acquisition of ABA organizations by conducting a Comprehensive Clinical Assessment (CCA). This thorough evaluation examines the strengths and opportunities of the ABA services, including reviews of key work products like session notes and treatment plans, site visits, and leadership interviews. The assessment covers clinical quality, compliance, and alignment with industry standards for service delivery, documentation, ethics, and supervision. With this detailed analysis, I provide valuable insights into how well the organization meets generally accepted ABA standards, highlighting areas for growth and improvement, and helping you make well-informed decisions.