My personal professional experience in Applied Behavior Analysis (ABA) agencies has been focused on working with students on the autism spectrum. It is vital for practitioners to maintain competent recordkeeping and documentation both the purposes of an audit as well as information to guide clinical decisions. There is a significant amount of data which may be kept in records, ranging from personal background information such as emergency contacts, insurance, consent, and medical history to information about the treatment process itself such as assessments, treatment plans, and progress reports.
Collectively, the information is necessary for a high-quality ABA practice which is why the places I worked at ensured to develop a strong system of data collection, with staff specifically trained for retaining and classifying data into records.
Confidentiality is highly important in ABA settings, particularly when working with children. In my capacity as an ABA professional, I am expected to abide by the Health Insurance Portability and Accountability Act (HIPAA) which legally protects the privacy and health information of individuals. It applies to ABA and autism spectrum disorders as well. Therefore, it is imperative to maintain the professional ethics and legal requirements in record keeping by maintaining patient confidentiality, properly disposing of all necessary or identifying paperwork, ensuring consent, avoiding discussion of client information even with an immediate supervisor, and protecting security of all records, both paper and electronic (Behavior Analyst Certification Board, 2014).
The complexity of both the regulatory framework and guidelines from the organizations such as the Behavior Analyst Certification Board (BACB) require ABA agencies to maintain sophisticated levels of recordkeeping. The regulations are even stricter when working with children or in educational settings as I did. Our records were commonly designated a level of privacy and filed digitally accordingly. There both access control policies and employee trainings which focused on teaching how to handle privacy or records. All physical and digital record locations were secured by either key or password to ensure security and protection in accordance to state and federal guidelines (Cavalari, Gillis, Kruser, & Romanczyk, 2014).
The setting where I worked, a variety of tools were used during work with kids on the autism spectrum disorder. This included fundamental patient data, assessments of various sorts, records of activities that were done during the session, as well as occasional video and audio recordings of the students and their sessions with a professional. It is normal and encouraged to maintain such cohesive and complete records in an ABA setting as both stated in guidelines by the APA and the BACB as they can be used for clinical, research, or supervision purposes. The records were stored on an internal network, and if analysis or research needed to occur, it was done in a secure setting.
I had to ensure that there was a specific individual record for each client. This included personal data as well as the start and stop times for each billable code. The documentation had to directly state the nature of the services provided previously and currently, the fees, identity of the ABA professional, specific outcomes for the patient, and other descriptive data. Daily documentation logs were kept as well to ensure that all records were updated consistently. It was important to ensure that all proper information, signatures, consent, and credentials were properly registered, legible, and appropriately filed.
References
Behavior Analyst Certification Board. (2014). Professional and ethical compliance code for behavior analysis. Web.
Cavalari, R. N., Gillis, J. M., Kruser, N., & Romanczyk, R. G. (2014). Digital communication and records in service provision and supervision: Regulation and practice. Behavior Analysis in Practice, 8(2), 176–189. Web.