Documentation

The Council of Autism Service Providers (CASP) Organizational Guidelines includes a chapter on documentation. In the chapter, documentation is defined as the "development of a permanent record of the services that a client has received." Providers and professionals involved in the delivery of applied behavior analysis (ABA) services within healthcare must have a thorough understanding of how to adequately record clinical activities within each client's medical record throughout treatment. Understanding how to document healthcare services in a client's medical record is essential for providing quality services as well as the continuity of care. If you or your organization is in need of training, education, or guidance on documentation of the following, contact RAW today:​

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• Assessment and treatment plans

• Discharge plans and summaries

• Session notes

• Coordination of care

Medical Necessity

Simply put, medical necessity generally requires documentation that the clinical need is legitimate and that the services provided are an appropriate response to that need (Adams & Grieder, 2014). Providers of applied behavior analysis must have a thorough understanding of this as a topic and how generally accepted standards of care in the field of applied behavior analysis (ABA) apply. The Model Coverage Policy provides the following as a definition:

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"Services must be medically necessary to ameliorate symptoms of a diagnosed disorder, build adaptive behaviors,
and/or reduce maladaptive behaviors to enhance the patient’s health, safety, and overall functioning and/or to
prevent deterioration or regression."

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How can a behavior analyst demonstrate services are medically necessary when performing an assessment, writing a treatment plan, or documenting services on a session note?

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 applied behavior analysis (ABA) services should prioritize establishing an internal compliance program. Not only is it recommended by the Office of Inspector General, but it supports safeguarding service delivery and the longevity of care.

Clinical Due Dliligence

Coming Soon