DISCLAIMER: **Formal CASP note templates will be available in future updates to Aloha DC, the below suggestions are inspired by CASPs published note templates and available training. 

** Individual payer requirements may supersede what is presented here, always check with your payer first.

Recommended initial information for all notes:

1. Client name
   
2. Client ID:
   
1. Can be date of birth (DOB) pulled using the client dynamic field drop down or a custom field can be added to the client profile to add their Insurance ID/Medical Record Number.
   
3. Client diagnosis:
   
1. Can be added via Appointment dynamic field drop down or a custom field can be added to the client profile to add their diagnosis
   
4. Provider name and credential
   
1. Add a custom field to the staff profile for credential information
   
5. Place of Service
   
1. Pull from the appointment dynamic field drop down or create a single select list for staff to select the location
   
6. Service modality:
   
1. Create a single-select list custom field for in-person and “HIPPA Compliant Telehealth”
   

Below is an image of how this information can be programmed into Aloha Data Collection's Lesson Note Templates.

The remainder of this article will present recommendations for session information and general fields that can be built into your session note templates. 

97151 - Behavior Identification Assessment - Lesson Note Additions:

Below is an image of how additional 97151 information can be programmed into Aloha Data Collection's Lesson Note Templates using Custom Data Fields

**Below is a Text version of the above information that can be copy/pasted into a Lesson Note Template. The text in black is text to be copy and pasted. The text in blue are instructions for implementation that should not be copied into note templates. 

Observational assessment: [N/A or narrative of activity here]
**Insert a Custom Data Field text box

Clinical interview: [N/A or narrative of activity here
**Insert a Custom Data Field text box

Records review/analysis of past data: [N/A or narrative of activity here]
**Insert a Custom Data Field text box

Administration, scoring, and/or analysis of assessments: [N/A or narrative of activity here]
**Insert a Custom Data Field text box

Preparation of report/treatment plan (plan of care): [N/A or narrative of activity here]
**Insert a Custom Data Field text box

97153 - Adaptive Behavior Treatment by Protocol - Lesson Note Additions

Below is an image of how additional 97153 information can be programmed into Aloha Data Collection's Lesson Note Templates using Custom Data Fields

Below is a Text version of the above information that can be copy/pasted into Aloha Data Collection. The text in black is text to be copy and pasted. The text in blue are instructions for implementation that should not be copied into note templates.

The interventions used to implement the protocol during the session are indicated by the checked boxes below:

**Insert a Custom Data Field multi-select list titled "Interventions CASP 53" (or similar) containing the commonly used, evidenced-based, interventions such as:

1. Discrete Trial Procedures
   
2. Modeling
   
3. Naturalistic Intervention 
   
4. Behavior Skills Training
   
5. Self-Management Techniques
   
6. Visual Supports
   
7. Video Modeling 
8. Forward Chaining
   
9. Backward Chaining
   
10. Total Task Presentation
    
11. Antecedent Based Intervention
    
12. Reinforcement of Incompatible Behavior
    
13. Reinforcement of Alternative Behavior 
14. Token Reinforcement
    
15. Most to Least Prompting 
    
16. Least to Most Prompting
    
17. Other **Insert additional text box Custom Data Field for "other" responses
    

97155 - Adaptive Behavior Treatment with Protocol Modification -  Lesson Note additions

Below is an image of how additional 97155 information can be programmed into Aloha Data Collection using Custom Data Fields. 

Below is a Text version of the above information than can be copy/pasted into Aloha Data Collection. The text in black is text to be copy and pasted. The text in blue are instructions for implementation that should not be copied into note templates.

Adaptive Behavior Treatment with Protocol Modification:

Face-to-face observations were made to determine if protocol components are functioning effectively for the client or require adjustments:

**Create a Custom Data Field single-select list titled "Face to face 55 Relevant Clinical Activities" (or similar) containing the following:

1. Face to face observations indicated that protocol components were functioning effectively and therefore no adjustments were made
   
2. Face to face observations indicated that the protocol components required adjustments
   
3. Not applicable
   

Narrative summary: 
**Insert Custom Data Field text box

Adjustments were made to the selected components of the protocol:

**Create a Custom Data Field multi-select list titled "Adjustments 55 Notes" (or similar) containing the following

1. Target treatments
   
2. treatment goals
   
3. Instruction
   
4. Materials
   
5. Observation and or measurement
   
6. Discriminative stimuli
   
7. Reinforcers
   
8. Reinforcer delivery
   
9. Prompts
   
10. Not applicable
    
11. Other
    

Narrative summary: 
**Insert Custom Data Field text box

Active direction (face-to-face) was given to a technician as they delivered ABA services:
**Create a Custom Data Field multi-select list titled "Active RBT direction activities 55 note" (or similar) containing the following:

1. Implementing the protocol with the client while the technician observed then having the tech implement the protocol with the client with QHP observe
   
2. Correcting errors made during the implementation of the adaptive behavior protocols
   
3. Modeling of correct implementation of the protocol
   
4. Training of the technician to implement a modified protocol
   
5. Providing feedback or instruction regarding the technicians implementation of the protocol
   
6. Observe or record sample of target behavior independently for IOA and identify retraining on behavior plans
   
7. Other
   
8. Not Applicable 
   

Narrative summary: 
**Insert Custom Data Field text box

Supervisor's implementation of the protocol with the client related to:
**Create a multi-select list containing the following:

1. Determining if changes were needed to improve client progress
   
2. Testing of a modified protocol
   
3. Other
   
4. Not Applicable

Narrative summary: 
**Insert Custom Data Field text box

Other Activities: 

**Insert Custom Data Field text box

97156 - Family Adaptive Behavior Treatment Guidance -  Lesson Note Additions

Below is an image of how additional 97156 information can be programmed into Aloha Data Collection using Custom Data Fields

Below is a Text version of the above information that be can copy/pasted into Aloha Data Collection. The text in black is text to be copy and pasted. The text in blue are instructions for implementation that should not be copied into note templates.

Session participants: (names and relationship to client)

**Insert Custom Data Field text box

Client participated:
**Insert Custom Data Field single select list titled "YesNo" (or similar) with options Yes and No

Family Adaptive Behavior Treatment Guidance:
The goals addressed via family adaptive behavior treatment guidance, the data collection method used, and the resulting data are presented below.
*Graphed data are stored within the client’s medical record and are available upon request.

The interventions used to implement the protocol during the session are indicated by the checked boxes below:

**Insert a Custom Data Field multi select list titled "Parent Training Interventions CASP" (or similar) containing the following options:

1. Behavior Skills Training
   
2. Video MOdeling
   
3. descriptive feedback
   
4. Modeling
   
5. Other 
   

Session Summary: 
**Insert Custom Data Field text box

Complete Visual Library

Below are examples of how different Lesson Notes may look when fully programmed into Aloha Data Collection's Lesson Note Templates

97151 Lesson Note

97153 Lesson Note

97155 Lesson Note

97156 Lesson Note