https://eauditor.app/
ABA Clinical Documentation Compliance Audit
Section 1: Documentation Accuracy
1. Is the client's name correctly documented in all records?
Yes
No
2. Are the dates of service accurately recorded?
Yes
No
3. Is the treatment plan updated regularly?
Yes
No
4. Are session notes completed for each visit?
Yes
No
5. Is the client's progress documented in each session note?
Yes
No
6. Are signatures from the clinician present on all documents?
Yes
No
7. Is the client's consent for treatment documented?
Yes
No
8. Are all billing codes accurately reflected in the documentation?
Yes
No
9. Is there a clear rationale for any changes in the treatment plan?
Yes
No
10. Are all assessments conducted and documented as required?
Yes
No
Section 2: ABA Clinical Documentation Audit
1. Is there a documented procedure for handling client complaints?
Yes
No
2. Are all staff trained on documentation standards?
Yes
No
3. Is there a system in place for regular audits of documentation?
Yes
No
4. Are treatment goals measurable and time-bound?
Yes
No
5. Is there a process for documenting client referrals?
Yes
No
6. Are all interventions documented with corresponding outcomes?
Yes
No
7. Is there a policy for maintaining client confidentiality in documentation?
Yes
No
8. Are all client interactions documented in a timely manner?
Yes
No
9. Is there a designated person responsible for overseeing documentation compliance?
Yes
No
10. Are all required forms and templates used consistently?
Yes
No
11. Is there a process for documenting changes in client status?
Yes
No
12. Are client discharge summaries completed and documented?
Yes
No
13. Is there a method for tracking client attendance at sessions?
Yes
No
14. Are all documentation practices compliant with HIPAA regulations?
Yes
No
15. Is there a feedback mechanism for improving documentation practices?
Yes
No