Generate AI Summary

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

Generate AI Summary helps clinical users draft the note summary from the structured data already entered in RBT and BCBA note forms. It reduces manual writing time while keeping the user responsible for reviewing and editing the final clinical narrative before saving the note.

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

• RBT/Analyst or other clinical user with RBT note access: Can generate an RBT summary when they can open the RBT create or update form.
• BCBA/Analyst or other clinical user with BCBA note access: Can generate a BCBA summary when they can open the BCBA create or update form.
• Admin / Owner / Manager / Superadmin: Can use the feature when their role gives them access to the related note workflow.

Required access depends on the underlying note form:

• RBT note creation and update use create_notes_rbt.
• BCBA note creation and update use create_note_bcba.
• manage_notes may apply when the user is allowed to select or manage another rendering provider, but it is not a separate requirement for the AI summary button itself.

3. Business Rules & Enforcements

• Rule 1: The button is available beside the summary field in the RBT and BCBA note forms. It does not save the note automatically.
• Rule 2: The generated text replaces the current summary field value. Users can review, edit, or rewrite the result before saving.
• Rule 3: The feature validates required form data before calling the AI service. If required data is missing, the UI shows a missing-fields warning and does not request a summary.
• Rule 4: Diagnosis, CPT code, POS, and POS description for POS 99 are required for generation.
• Rule 5: Session time is required for generation except for CPT 97153.
• Rule 6: RBT generation requires behavior and session data, including maladaptive behavior data, replacement behavior data, interventions, antecedents, mood/client presentation, evidence, progress, and caregiver modeling information.
• Rule 7: RBT required replacement goals must include valid trial or first-trial step data. First-trial completed steps cannot be negative or greater than total steps.
• Rule 8: BCBA generation applies CPT-specific rules:
  • 97151 requires an assessment type. Observation/Parent Interview also requires assessment procedures, assessment tools, and intake/outcome measurements.
  • 97155 requires participants, environmental changes, maladaptive and replacement data, at least one protocol modification, protocol modification details, and progress compared to the previous session.
  • 97156 requires demonstrated replacement protocols, demonstrated intervention protocols, discussed behaviors, participants, environmental changes, and progress compared to the previous session. Caregiver goals are required when the selected POS is allowed for caregiver training by the insurance setup.
  • 97153 BCBA generation is currently blocked with a “not implemented yet” validation message.
• Rule 9: For BCBA 97151 report summaries, the system checks prior report notes for the patient and uses the next report iteration as context for the generated narrative.
• Rule 10: If the AI service fails, the UI shows an error message and leaves the existing summary field available for manual editing.

4. UI Placement

1. RBT note create/update form: The Generate AI Summary button appears next to Note’s Summary.
2. BCBA note create/update form: The Generate AI Summary button appears next to Summary Note.
3. RBT generation endpoint: /note_rbt/generate-summary.
4. BCBA generation endpoint: /note_bcba/generate-summary.

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

Scenario A: Generate an RBT note summary

1. Open the RBT note create or update form.
2. Complete the required session, POS, behavior, replacement, intervention, antecedent, progress, and caregiver modeling fields.
3. Click Generate AI Summary beside Note’s Summary.
4. If the system shows a missing-fields warning, complete the listed fields and click Generate AI Summary again.
5. Review the generated summary in the summary text area.
6. Edit the text as needed for clinical accuracy.
7. Save or update the note through the normal note workflow.

Scenario B: Generate a BCBA note summary

1. Open the BCBA note create or update form.
2. Select the CPT code and complete the CPT-specific section for 97151, 97155, or 97156.
3. Complete POS, time, participants, environmental changes, progress, and any required assessment, protocol, caregiver, teacher, maladaptive, or replacement data.
4. Click Generate AI Summary beside Summary Note.
5. If the system shows a missing-fields warning, complete the listed fields and click Generate AI Summary again.
6. Review and edit the generated text before saving the note.
7. Save or update the note through the normal note workflow.

Scenario C: Regenerate a summary after editing form data

1. Update the relevant form fields.
2. Click Generate AI Summary again.
3. Review the new text because it replaces the previous summary field content.
4. Make any final clinical edits before saving.

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

• Q: What happens if the user clicks Generate AI Summary before completing required data? A: The system shows a warning with the missing fields and does not send the request until the user completes the required information.

• Q: Does the AI-generated text save the note automatically? A: No. The generated text only fills the summary field. The user must still review the content and save or update the note.

• Q: What happens if the generated text is not clinically accurate enough? A: The user can edit the summary manually or regenerate it after updating the form data. The final note content remains the user’s responsibility.