Create RBT Note

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

This feature allows an authorized user to create an RBT note for a completed therapy session. It captures service date, session time, provider and supervisor information, behavior data, interventions, antecedents, and the final clinical summary needed for accurate treatment records and billing readiness.

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

• RBT/Analyst or other clinical user with create_notes_rbt: Can open the create form and submit an RBT note in the current authorized location.
• Admin / Owner / Manager / Superadmin with create_notes_rbt: Can create RBT notes when their role includes the creation permission.
• Users with manage_notes: Can select a different rendering provider on the form. This permission supports operational correction or delegated documentation, but the create action still depends on RBT note creation access.

Required permissions:

• create_notes_rbt

Related permission:

• manage_notes for selecting another rendering provider.

3. Business Rules & Enforcements

• Rule 1: Creation is scoped to the user’s authorized location and patient access.
• Rule 2: Session date is required, cannot be in the future, and must fall inside an active primary RBT PA service range for CPT 97153.
• Rule 3: The note requires a patient, rendering provider, BCBA supervisor, PA service, location, session date, POS, at least one valid time period, and required clinical content before it can be saved.
• Rule 4: Time periods must be chronological. Future times in the location timezone, overlapping sessions for the same patient, backdated sessions outside allowed limits, CPT limit issues, and PA weekly unit limit issues are rejected unless the user has the relevant override permission.
• Rule 5: A BIP is required for creation. If no BIP is found, the user receives a warning and the save action is disabled in create mode.
• Rule 6: Antecedents are required. Maladaptive behaviors, replacement goals, interventions, participants, environmental changes, client presentation, evidence, caregiver modeling, progress, next session date, and summary note are also checked before save.
• Rule 7: Replacement and maladaptive validation is enforced:
  • Required maladaptive behaviors must include occurrences.
  • Required replacement goals must include trials and correct responses.
  • First-trial replacement goals must include valid step completion data and cannot use normal trial totals.
• Rule 8: POS 99 requires a POS description.
• Rule 9: next_session_is_scheduled_for must be on or after the current session date.
• Rule 10: The summary note is required by the UI and must satisfy the backend minimum length.
• Rule 11: AI summary generation is available from the form. It uses the current form data and can only run after required plan data is present; users can review and edit the generated text before saving.

4. UI Placement

1. Medical > Patients List > Patient actions > Create RBT Note.
2. RBT Notes by client > plus button when the user has create_notes_rbt.
3. Create route: /medical/note-rbt/:patient_id.
4. Appointment-based route: /medical/note-rbt/:patient_id/:appointment_id, which preloads patient and appointment context when the note is started from an appointment.

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

Scenario A: Create a new RBT note

1. Go to Medical > Patients List.
2. Open the patient actions menu and select Create RBT Note.
3. Wait for the system to load the patient, BIP data, PA services, supervisors, and available rendering providers.
4. Confirm the rendering provider. For standard providers this is auto-filled; users with manage_notes can select another provider.
5. Select the DOS. The system matches the date to an active primary RBT PA service for CPT 97153.
6. Enter at least one valid time-in/time-out period. Use the second time block only when the session was split.
7. Complete POS, participants, environmental changes, antecedents, maladaptive behaviors, replacement goals, and interventions.
8. Complete the clinical narrative fields, including client presentation, evidence, caregiver modeling, progress, next session date, and summary note.
9. Optionally generate the AI summary, review it, and adjust the text as needed.
10. Click Save. After a successful save, the user is returned to the patient’s RBT notes view.

Scenario B: Create an RBT note from an appointment

1. Open the appointment workflow that starts an RBT note.
2. Confirm that patient and appointment details are preloaded correctly.
3. Complete the same clinical, time, PA, behavior, intervention, and summary fields required for a normal RBT note.
4. Click Save and confirm that the note appears in the patient’s RBT notes view.

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

• Q: What if the patient has no BIP configured? A: The user sees a BIP missing warning. In create mode, save is disabled because the note depends on BIP maladaptive, replacement, and intervention data.

• Q: What if there is no active/valid PA for the selected DOS? A: The form warns that the date is outside the PA service range, clears the selected date, and directs the user to correct the service setup or choose a valid date.

• Q: What if required fields are incomplete or the summary is too short? A: The UI shows a missing-fields list where possible, and backend validation prevents saving until the data meets the required rules.