Create BCBA Note

1. What does this feature do? (High-Level Overview)

This feature allows authorized staff to create a BCBA clinical note for a patient session and save it under the patient record. It supports assessment (97151), protocol modification (97155), and caregiver training (97156) workflows, including appointment-prefilled notes and optional AI-assisted summary generation.

2. Who is this for? (Roles & Permissions)

• BCBA/Analyst: Can create a BCBA note when they have patient and location access and the create_note_bcba permission.
• Admin / Owner / Manager / Superadmin: Can create BCBA notes when they have the required note permission and location access.
• Users with manage_notes: Can select the rendering provider and supervisor instead of using the default provider context.

Required permissions:

• create_note_bcba: Required to save a new BCBA note through the V2 notes API.
• manage_notes: Enables provider and supervisor selection in the form.

3. Business Rules & Enforcements

• Rule 1: The note cannot be saved without a patient, date of service, rendering provider, supervisor, CPT/service, client location (POS), at least one complete time block, and a summary note.
• Rule 2: The session date cannot be in the future, and entered session times cannot be in the future for the patient’s location.
• Rule 3: Time blocks must remain chronological: Time Out must be after Time In, and a second block can only start after the first block ends.
• Rule 4: Time overlap, time limits, backdated note limits, CPT limits, and weekly PA service units are validated unless the user has the applicable override permission.
• Rule 5: The selected date must match an active PA service window. BCBA CPT choices come from active primary PA services available for the selected date.
• Rule 6: New 97151, 97155, and 97156 notes require an associated BIP. If no BIP exists, the form blocks saving after the relevant CPT is selected.
• Rule 7: When creating a 97151 note, the system checks for a prior 97151 note with subtype Observation in the last 60 days. If none exists, the new 97151 must use Observation; otherwise, creation is rejected. If one exists within 60 days, other 97151 subtypes are allowed. When violated, the API returns HTTP 422 with: Cannot create first BCBA note 51: the first BCBA note must be an observation/parent interview.
• Rule 8: If the insurance requires telehealth classification, Is this note Telehealth? is mandatory. For 97151, telehealth POS values show a warning reminding the user to confirm telehealth compliance.
• Rule 9: If POS 99 is selected, a POS description is required.
• Rule 10: The participants field must contain real names. Generic labels such as roles or family labels are rejected by UI validation.
• Rule 11: 97151 requires a subtype and may require assessment-specific inputs such as stage, assessment tools, and intake outcomes.
• Rule 12: 97155 requires participants, environmental changes, progress since the previous session, at least one maladaptive frequency, at least one replacement percentage, at least one protocol modification, and meaningful protocol-change narratives.
• Rule 13: 97156 requires participants, environmental changes, progress since the previous session, and caregiver goal data when the selected POS is allowed for caregiver goals by the patient’s insurance.
• Rule 14: When automated modifier rules apply, the backend may assign modifiers during creation unless the user already provided modifiers.
• Rule 15: If the note is saved as billed, the backend marks billing edits as blocked for future updates.
• Rule 16: AI-generated summaries are optional support content; the user remains responsible for reviewing the final summary before saving.

4. UI Placement

1. Notes > BCBA Notes: Users can open the BCBA note workflow from the notes area.
2. Patient BCBA note creation route: The creation screen loads at /note-bcba/:patient_id.
3. Dashboard / Calendar appointment flow: Opening a qualifying appointment can route the user to /note-bcba/:patient_id/:appointment_id with session details prefilled.

5. How-To Guide (Step-by-Step)

Scenario A: Create a BCBA note from a patient

1. Open the BCBA note creation screen for the patient.
2. Wait for the patient record, specialists, insurance, PA services, and BIP-linked clinical goals to load.
3. Confirm the rendering provider and supervisor. Users with manage_notes may select different values.
4. Select the date of service.
5. Choose an active BCBA CPT/service for that date.
6. Enter the first session time block and, if needed, a second session time block.
7. Select the POS where the client was seen and enter a POS description if POS 99 is used.
8. If the insurance requires it, answer the telehealth question.
9. Complete the CPT-specific clinical section.
10. For 97151, choose the subtype and complete the assessment-specific fields.
11. For 97155, complete protocol modification, maladaptive, replacement, RBT goal, and progress fields.
12. For 97156, complete caregiver training, behavior protocol, caregiver or teacher goal, and progress fields.
13. Enter environmental changes and the names of the people present when required.
14. Write or generate the summary note, then review it.
15. Review the provider and supervisor signatures shown on the form.
16. Click Save.

Scenario B: Create a BCBA note from an appointment

1. Open the appointment from the dashboard or calendar.
2. If the appointment does not already have a related note, the app opens the BCBA note creation screen.
3. Review the prefilled patient, date of service, rendering provider, CPT, POS, and time information imported from the appointment.
4. Complete the remaining clinical fields required for the selected CPT.
5. Write or generate the summary note and review it.
6. Save the note.

6. What happens if…? (Edge Cases / FAQ)

• Q: What happens if the patient does not have a BIP and I select a BCBA CPT? A: The form warns that the patient needs an associated BIP and disables saving for the new note.

• Q: What happens if there is no active PA service for the selected date? A: The UI warns that the service date is outside the PA range, and the user is advised to contact the office.

• Q: What happens if the note is the patient’s first recent 97151 note and I try to save a different subtype? A: The backend rejects the creation with HTTP 422 and returns: Cannot create first BCBA note 51: the first BCBA note must be an observation/parent interview.