How the client presented at the start of the session, as selected or described by the clinician. Report affect, engagement, or readiness only if the clinician described it; do not characterize the client's mood, motivation, or willingness

Any barriers to treatment (e.g., illness, fatigue, environmental changes, schedule disruptions). Report the barrier and the session events separately; do not state or imply that a barrier caused a change in performance. Report each barrier once, in the barriers portion of the narrative - do not restate it as an interfering behavior or as a response to intervention. Attribute reported information to its source (for example, "caregiver reported..."). Do not name medications, doses, or diagnoses

Interfering/problem behaviors that occurred, described with measurable dimensions (frequency, duration, magnitude/intensity), plus antecedents and consequences (if noted), using the behavior names as written in the treatment plan

Name a goal or intervention only where it is needed to make a sentence about the client's response intelligible. Do not enumerate them. Do not state which target a given intervention was applied to, or in what sequence, unless that is recorded on the note

The prompting procedures and prompt levels used, as recorded in the session data

How the client responded to prompts and interventions (e.g., independent vs. prompted responding, accuracy, trials)

Describe what the data show about the client's responding: patterns across trials, changes within the session, and any target where responding differed from the rest of the session. Do not restate trial counts, percentages, or target lists that appear in the data summary section. Do not assert that the client is progressing or regressing, and do not characterize data as unusual, unexpected, or emerging

Targets addressed for maintenance with no data collected: state that they were addressed and that no data were recorded this session

Next steps: state the option the clinician selected - continuing the plan as written, or requesting supervisor consultation. Do not choose between them and do not recommend a plan change

Tie behaviors, interventions, and outcomes to the client's treatment-plan goals/targets; keep the account objective and measurable. Do not use subjective language. Where a structured option itself contains a judgment word - for example "smooth," "maladaptive," "poor," "excessive," or "high rates" - report what the option denotes rather than repeating the judgment, and attribute it as the clinician's selection. If a selected option conflicts with the collected data, report the data and omit the characterization

Generate content only for the narrative field being requested. Do not reproduce the narrative in other sections of the note

The narrative should reflect the full session as documented. Cover one session only; do not combine separate AM and PM sessions or carry content forward from a prior session

Keep the narrative under [SET PER ORG] words regardless of session duration. Use paragraphs of no more than four sentences, sentences under 20 words, and vary sentence openings between paragraphs

Do not use subjective phrases such as "Client had a good day," "Client enjoyed...," or "Client was stubborn/defiant"

Do not state that the client generalized a skill, that responding was above or below baseline, or that behavior rates were high or low. Report the observation; leave the determination to the supervising BCBA

Do not mention interventions that were not implemented

Whether a behavior technician was present and, if so, the direction or coaching provided, the technician's name and credentials as entered, and why that direction was necessary for this client's progress

How the client presented at the start of the session (affect, engagement, readiness to work), as described by the clinician

Barriers to treatment observed during the session. Report the barrier and the session events separately; do not state that a barrier caused a change in performance

Interfering/problem behaviors, described with measurable dimensions, plus antecedents and consequences (if noted)

The targets/programs worked on and the interventions implemented, named as written in the protocol. Do not enumerate lists the note carries elsewhere

The prompting procedures and prompt levels used, as recorded in the session data

How the client responded to interventions and any modifications

A data summary tied to named goals/targets: performance relative to targets, progress or mastery status, emerging skills, and anything unusual or unexpected - reported as the clinician recorded it. Do not restate trial counts or target lists that appear in the data summary section

The clinician's interpretation of the data, as entered. Do not generate an interpretation, infer what the data mean, or characterize findings the clinician did not characterize

Protocol modifications made during the session by component, as selected, and the data-based or clinical rationale for each as the clinician stated it. If no rationale was entered, describe the modification without one - do not supply a plausible rationale

Next steps as the clinician indicated them. Do not choose among continuing, modifying further, gathering more data, or adjusting technician direction

Where the modification is documented in more detail elsewhere, state that additional detail is available rather than reconstructing it

Tie behaviors, interventions, modifications, and outcomes to the client's treatment-plan goals/targets; keep the account objective and measurable. Do not use subjective language. Where a structured option contains a judgment word, report what it denotes rather than repeating the judgment. If a selection conflicts with the collected data, report the data

Each protocol modification should be connected to the observation or data that prompted it as recorded on the note

The narrative should reflect the full session as documented. Cover one session only

Emphasize what the QHP did and why - observation, modification, technician direction, feedback delivered - rather than summarizing trials run

Use paragraphs of no more than four sentences and sentences under 20 words.

Write session-specific content. Do not produce text that could apply to any session for this client, and do not reuse phrasing from previous notes

Who participated in the session (e.g., which caregiver(s)/family members) and their relation to the client, as entered, and whether the client was present or did not participate

The caregiver goals or targets addressed during the session

The strategies, procedures, or concepts taught or reviewed with the caregiver(s)

How the guidance was delivered (e.g., discussion, modeling, role-play, or in-vivo coaching)

How the caregiver(s) practiced or demonstrated the strategies, including accuracy or implementation fidelity where noted - reported as recorded. Do not characterize caregiver skill, motivation, or receptiveness beyond what was entered

The feedback provided to the caregiver(s)

Caregiver questions, concerns, or level of understanding

Barriers affecting implementation as reported or observed. Report the barrier and the session events separately rather than asserting a causal effect

A summary of caregiver performance and progress relative to goals/targets, including anything unusual or unexpected

The clinician's interpretation of the observations, as entered. Do not generate an interpretation the clinician did not provide

Next steps: home practice or assignments, focus for the next session, or areas needing additional support as the clinician indicated them

Caregiver reports of how the client responds to protocols the caregiver implements outside these sessions, attributed to the caregiver rather than stated as observed

New caregiver concerns that may require future protocol modification, noted as raised rather than as decisions. Protocol changes are made under 97155

Information the caregiver provided that warrants a referral or a change in care coordination, and the clinician's stated action. Report that a caregiver-reported medication change occurred without naming medications or doses

Treatment fidelity data as implemented by the caregiver, and interobserver agreement between caregiver and clinician, where recorded

If the client was present, how the client responded to the caregiver

Keep the narrative focused on guidance provided to the caregiver(s), not direct treatment delivered to the client - which, where it occurred concurrently, is a separate service documented under 97153

Tie strategies taught, caregiver performance, and outcomes to the caregiver/treatment-plan goals; keep the account objective and measurable. Do not use subjective language.

The narrative should reflect the full session as documented. Cover one session only

Do not include information already contained elsewhere in the session note

Use paragraphs of no more than four sentences and sentences under 20 words

Write session-specific content. Do not produce text that could apply to any session for this caregiver, and do not reuse phrasing from previous notes

Do not assert that the service was medically necessary. Document what was done, why, how the caregiver responded, and how it relates to the caregiver goals

Whether this was an initial assessment or an authorization/review reassessment, as selected. Use the selected term rather than a general reference to assessment

The authorization or review period covered

Assessment methods used (e.g., record/chart review, direct observation, standardized and criterion-referenced assessments, caregiver or stakeholder interviews, data analysis), with the specific activity for each: what was conducted, where, and the stated purpose

The assessment instruments used, named as entered, and whether each was administered, scored, or analyzed. Do not report scores, subscale results, or interpretations that were not entered

For interviews, the interviewee's relation to the client as entered

For record review, the types of records reviewed

Non-face-to-face work performed, including report or treatment plan preparation and its status

Discussion with caregivers regarding findings and recommendations, including whether they agreed and whether recommendations were modified following that discussion

The client's clinical status as the clinician described it: readiness, attending behaviors, instructional control, motivating factors, and how the client presented during the assessment. Where this is a reassessment and the clinician noted change since the last review, report the change as the clinician characterized it

Barriers that affected progress during the review period, as selected and described. Report each barrier once. A barrier entered in more than one field is still a single barrier and should appear in the narrative only once

Progress across the review period and emerging skills: for each goal, program, or target the clinician listed, its status (mastered, in progress, modified, or discontinued) and performance relative to targets, as entered. Do not assign a status the clinician did not record, and do not infer status from performance figures

Interfering behavior status with measurable dimensions as recorded. Do not compute or assert comparisons to baseline or prior data that were not entered

Newly identified concerns or areas needing additional focus as the clinician identified them

The clinician's interpretation as entered. Do not generate an interpretation of response to treatment or of continued need for services

Updated goals/targets and recommended changes to the treatment plan as entered, with a reference to the treatment plan for detail

Recommended service types, amounts, and rationale, as entered

Next steps (e.g., continue the plan as updated, adjust services, or follow-up assessment) as the clinician indicated them

Tie progress, behaviors, and recommendations to the client's treatment-plan goals/targets; keep the account objective and measurable

Frame interpretation and recommendations around the data presented, without asserting medical necessity conclusions the entered information does not support

Report each item of information once. Where the same barrier, observation, or status appears in more than one field, consolidate it rather than repeating it

Do not state, confirm, or restate a diagnosis, or assert that diagnostic criteria are met. Diagnosis is established in a separate diagnostic report

Keep the narrative under [SET PER ORG] words. Use paragraphs of no more than four sentences and sentences under 20 words

Write session-specific content. Do not produce text that could apply to any assessment for this client, and do not reuse phrasing from previous notes