Clinical
Session Notes & Documentation
Session Notes & Documentation is Coralia's clinical documentation module for applied behavior analysis (ABA) agencies: every therapy encounter under CPT (Current Procedural Terminology) codes 97151–97158 becomes a gated note that moves from draft to submitted to approved, collects three legal e-signatures, and only then becomes eligible for billing.
The problem in real agencies
In ABA, the session note is the payer's evidence that care happened as billed. When a payer audits a claim for one-to-one treatment (CPT 97153) and the note is missing who was present, whether the guardian was there, or actual data on the targets worked, the agency repays that money — sometimes years of it. Most documentation tools accept whatever the therapist types and leave completeness to chance.
The review chain has its own failure modes. Supervising analysts approve notes days late with no visibility into what is overdue. Signatures are typed names with no record of what was signed, when, or under which credential. Notes get edited after signing with no trail. And a note that was never reviewed at all can still slide into a claim batch.
Behind every note sits an authorization with finite units and a credential rule about who may render each code. Agencies that track this in spreadsheets find the mismatch after the denial: a Registered Behavior Technician (RBT) rendered a supervision-only code, a session ran past its authorized units, a claim went out against an expired authorization. The documentation system is the last place these errors can be caught before money is at stake.
How it works in Coralia
- 1
The note matches the credential
An RBT documents through a Session Summary, a Daily Log, and per-target data — the four SOAP (Subjective, Objective, Assessment, Plan) sections are hidden from that role. A Board Certified Behavior Analyst (BCBA) or assistant analyst (BCaBA) note requires all four SOAP sections plus a summary before submission. A 97151 assessment observation uses a structured template instead: activities conducted, setting, people present, antecedent-behavior-consequence (ABC) rows with a hypothesized function, and clinical impressions. A credential gate maps every CPT code and modifier combination to who may render it, enforced when the session is created and on every edit.
- 2
Submit gates enforce payer-grade completeness
A direct-care (97153) note cannot be submitted without documented attendance: who was present, a guardian-presence attestation, and a written reason when the guardian was absent — a Florida Medicaid documentation point. Every target a technician collects must carry at least one real data point and the Daily Log must be complete, or a documented no-data reason must excuse both. Agencies can layer their own policies on top: a minimum narrative length, a restricted-word list that blocks submission, a rule that no note is submitted before the session has ended, and a required signed attestation before any note enters review.
- 3
Three signatures stand between a note and a claim
The renderer signs at submission with a hand-drawn signature — a typed name is rejected. The supervising analyst signs at approval; the reviewer must be a different analyst with an active supervisory assignment to that client, so no one reviews their own work. (97151 assessments, where the authoring BCBA is the qualified professional, self-finalize in one signed step.) The caregiver signs the caregiver visit verification at point of care — confirming date, time, and duration, not clinical content — with no portal login required. Each signature is an append-only attestation carrying a sha256 hash of the exact note content signed.
- 4
From submitted to approved
A submitted note goes to the supervising analyst for review. Approving it consumes authorization units — moving them from reserved to used — and requires an approved, unexpired authorization matching the procedure code; an approved, fully signed note becomes claim-eligible. Sending a note back as Needs Revision notifies the author, and the reviewer's coaching notes land on the note itself. The pending-review queue supervisors work from — its mine-to-sign scope, overdue counter, and batch approval — is documented on the Supervision & Oversight page.
- 5
Optional AI review before a human ever signs
Authors can send a draft to Sentinel, Coralia's autonomous note reviewer, for a pre-submit check. Coaching lands directly on the still-editable note, ranked across five severity levels from hard-stop to low, and one full review is allowed per note. Each agency sets the flow to off, recommended, or required — in required mode submission stays blocked until the review returns, with an escape valve after one hour or a failed review so an outage never blocks documentation.
- 6
Versioned, audited, and retained
Every edit to a SOAP field snapshots the previous encrypted content into an immutable version row; every edit or deletion of a target datum writes an append-only snapshot in the same transaction. Concurrent edits fail with a refresh prompt instead of silently overwriting each other. Canceling returns authorization units to the ledger and is impossible on a billed session until its claim is voided. A signed note can only be permanently deleted by an Agency Admin with a written reason, which formally revokes the surviving signatures as a reasoned tombstone.
The specifics
Six note statuses — Draft, Submitted, Approved, Needs Revision, Canceled, and No-Show — each with a color-coded badge.
Seven data-collection types per target: trial, frequency, duration, latency, interval, task analysis, and probe.
Eight versioned attestation statements cover note submission, supervising analyst approval, caregiver visit verification, supervision sign-offs, and report finalization.
Nine billing modifiers cataloged (TS, HN, XP, GT, UN, UP, UQ, UR, US); the credential gate enforces each CPT-and-modifier combination.
Billing units follow the Centers for Medicare & Medicaid Services (CMS) 8-minute rule by default, or completed-15-minute increments per payer; sessions cap at 8 hours.
The Daily Log records environment, prompt levels (six, from independent to full physical), ten teaching methods, and five reinforcer types.
Behavior incidents capture a narrative with setting, intensity (mild, moderate, severe), and duration; removed incidents stay visible to auditors through soft-deletion.
Concurrent edits are caught by optimistic locking: a stale edit fails with a prompt to refresh instead of silently overwriting another user's work.
Built for HIPAA compliance: all clinical narrative is encrypted at rest, and every protected health information (PHI) write is audit-logged by field name, never by content.
Integrations
Calendar & Scheduling — sessions draw appointments on the agency calendar, and time edits or cancellations sync to the linked event · Sentinel — Coralia's autonomous note auditing acts as the optional pre-submit reviewer inside the note editor · Authorization Tracking — units reserve on scheduling, move to used on approval, and return to the ledger on cancellation · Billing & Revenue Cycle — approved, fully signed notes become claim-eligible; claims are created only by an explicit admin action
Access control
Eight session-level permission codes separate viewing (own caseload or agency-wide), creating, editing, approving, deleting, blank-draft deletion, and coverage-gate override, so an RBT's rights differ from a BCBA's or an administrator's. Object-level scoping applies on top: assistant-category staff see only clients they are connected to, reviewers must hold an active supervisory assignment to the client, and permanently deleting a signed note requires an Agency Admin with a written reason.
Frequently asked questions
What does an RBT need to complete before a direct-care session note can be submitted?
A direct-care (97153) note cannot be submitted until attendance is documented — who was present plus a guardian-presence attestation, with a written reason when the guardian was absent — every collected target carries at least one real data point or a documented no-data reason, and the Daily Log is complete. Agencies can also require a minimum narrative length and block configured restricted words. Submission itself requires the therapist's hand-drawn signature; a typed name is rejected.
How do e-signatures on session notes work?
Each signature is an append-only attestation structured for the federal ESIGN Act and the Uniform Electronic Transactions Act (UETA). It freezes the signer's name (encrypted), a snapshot of their credential at signing, the exact attestation wording and its version, a sha256 hash of the signed note's content, and the signing IP address and browser. If a signature is later revoked, the original record is preserved rather than erased.
What happens to a note after approval?
Approval moves the session's authorization units from reserved to used and requires an approved, unexpired authorization matching the procedure code. The note then becomes claim-eligible once it carries all three signatures — renderer, supervising analyst, and caregiver; the one exception is 97151 assessment observations, which bill off the conducting analyst's signature and the signed treatment plan. Claims themselves are generated in a separate, deliberate step by an administrator in Billing — never automatically — and a path-to-claim card on each session shows exactly which steps remain.
What happens when a note is edited or deleted after signing?
Every edit to a clinical narrative snapshots the previous encrypted content into an immutable version history, and every change to recorded target data writes an append-only snapshot in the same transaction. A signed note can never quietly disappear: permanent deletion requires an Agency Admin with a written reason, which formally revokes the surviving signatures while preserving them as a record. Billed sessions cannot be deleted at all until their claim is voided.
Is AI review of session notes required?
It is an agency choice. Authors can send a draft to Sentinel, Coralia's AI reviewer, before submitting; coaching lands on the still-editable note ranked across five severity levels. Each agency sets the mode — off, recommended, or required. In required mode the submit stays locked until the review returns, with an escape valve after one hour or a review failure, so an outage never stops a therapist from submitting.