Producing excellent reports need not be an exercise in reinventing the wheel each time, but rather one based on the creation -- and consistent use -- of excellent report templates.
Templates serve as an instruction manual to the report writer ensuring that all the vital and required information is always included, while leaving room for the writer to exhibit his/her professional expertise. They create a mechanism through which you can feel confident that bringing on new professionals will not derail or slow the funding source pipelines you have successfully cultivated. And, they afford an efficient (READ: cost saving) method for getting the job done right consistently.
As an ABA provider you wear many hats, often at the same time. As a clinician, you provide an array of services to clients and their families; and as an employee or owner, you are responsible for reporting to funding sources, supervisors and families on what you intend to do, what you are actually doing (and how it’s going), and what will happen when you are no longer providing services.
The reports you write and submit are the tool you use to share vital information with your clients and their families, as well as with your funding sources.
Bottom Line: Even if you and your people are doing a great “clinical” job, if you are not able to convey that in your reports, you may be in danger of losing clients and/or funding.
This report is your key to securing funding. A properly constructed and detailed Initial Assessment Report and Treatment Plan is your way of informing the prospective funding source (and family) of several important things:
You are an expert in your field – This is your opportunity to show that you are a behavioral health professional capable to deciphering the information gleaned during the assessment and from other resources and transforming it into a properly constructed treatment plan. What assessments did you use? How did you perform the assessments? What other data sources did you include? What do you know about your client/family? Who will be involved in the treatment process?
You know your “clinical stuff” – Where do the goals in your treatment plan come from? How are your goals defined? Do your goals meet with funding source “criteria”? How are you going to work towards the mastery of those goals? How will you know (and document) if progress is, if fact, being made? What will you do if progress is not being made? How many hours of service will be required to achieve the goals? What is your “justification” for the service request you submit?
You know your “legal/funding source stuff” - Does your treatment plan meet with the specific legislative criteria detailed in your state’s autism insurance reform law? Does the funding source have its own list of “requirements”? Have you gathered all the required documents and are you able to show you have all the essential components required to secure funding?
You know what qualifications are required for each clinical role involved in the implementation of the treatment plan – Who will/can create the treatment plan? Who will implement it? What kind and how much clinical supervision is required? Who can modify the treatment plan?
2. Progress Report
A great treatment plan and its expert implementation are vital to the client’s progress. So how do you show that progress is being made? That you are “on top” of the clients’ needs?
An amazing progress report is your way of conveying that:
You are an expert in your field – Yes, I did say this already with the Initial Assessment Report and Treatment Plan, but commencing services does not afford you the liberty of dropping the ball. How has the client progressed on your goals? How have you modified those goals? Why? Why not? Have things changed in the client’s world? Has that impacted progress on goals? Is the family properly involved? How do you know/document family involvement in the treatment process?
You can support your clinical recommendations – This is where having excellent/robust supporting documentation is imperative. Just saying that the client showed improvement won’t fly! Do you have consistent data tracking forms? Can you provide documentation for any plan modifications? What those modifications were and why they were implemented? Who instructed that they be implemented? What happened after they were implemented? Who implemented the change? Were the parents/caregivers “on board”?
You have a clear vision for what comes next – The progress report is not only a platform to describe what happened thus far, but also how you see things moving forward. What should stay the same? What should change? And why? What’s the justification for your recommendations?
3. Exit Report
An exit report isn’t something you should ignore, make light of, or put on the back burner for later. It is a “must” both clinically and ethically for your client, and financially/administratively for your funding source. So do a great job, report on all goals, make suggestions and recommendations for what to do next, how to ensure that there is as little “back-sliding” as possible, and leave the door open for help and communication.
Remember, sending a client off “into the world” with an excellent exit report reflects brightly back on you.
Need help creating those amazing report templates? Aren't sure what the insurance companies are looking for? Check out the Documentation ToolKit for a complete set of essential clinical and administrative documents, safety and security forms, report templates, policies and procedures and much much more all created exclusively for autism treatment providers.