Creating Session Notes and Progress Documentation

Overview

Session notes in Onvelas are tied directly to appointments. A complete note serves as the clinical record and the billing backup document. Many payers can request session notes during an audit, so accuracy and timeliness matter.

Step 1 — Open the Appointment

1. Go to Scheduling in the left sidebar.
2. Click on the completed appointment for which you need to write a note.
3. Click Add Session Note in the appointment detail panel.

Step 2 — Complete the Note Fields

A compliant ABA session note should include:

• Session date and time — auto-filled from the appointment
• Rendering provider — the technician or BCBA who delivered the service
• Supervising BCBA — required for RBT-rendered services
• Procedure code and units — must match what will be billed
• Goals addressed — at minimum, reference the treatment plan target areas
• Patient response — behavioral observations and measurable progress data
• Caregiver involvement — note whether caregiver training occurred (required for 97156/97157)
• Next session plan — brief summary of the next treatment focus

Step 3 — Link to the Treatment Plan

In the Goals section of the note, select the active treatment plan targets you addressed. This links your documentation to the authorized plan of care, which is required by most Medicaid payers.

Step 4 — Submit the Note

1. Review all fields for completeness.
2. Click Save and Sign. Your electronic signature is applied automatically using your logged-in credentials.
3. For BCBA-supervised sessions, the supervising BCBA may need to co-sign — they will receive an in-app notification.

Documentation Tips

• Complete notes the same day — most payers require documentation within 24–72 hours of service delivery.
• Be specific — "Patient completed 8 out of 10 trials at 80% accuracy" is better than "Patient did well."
• Match units to time — if you bill 4 units of 97153 (1 hour), your note should reflect 60 minutes of direct therapy.
• Never back-date — electronic records are time-stamped; alteration constitutes fraud.

Supervisor Co-Signature

When a note requires BCBA co-signature, the supervising provider sees a Pending Co-Signature badge on their dashboard. They can review and sign directly from the notification or from the patient's clinical record.