Intervention generates documents from the first contact to discharge. Keeping this set organized protects the child, family, and professional, and saves time when school, a doctor, or health insurance requests information.

This text is a practical guide and does not replace legal advice or the standards of your professional licensing board. Confirm requirements with an attorney and your professional licensing board.

Before starting

  • Service contract: scope, frequency, session location, fees, absences, make-up sessions, and cancellations.
  • Informed consent: what will be done, goals, risks, and the right to discontinue.
  • Authorization for image use and recording: if the team records sessions for supervision or to show the family, this must be authorized in writing, including the purpose and who will have access.
  • Registration form and intake history: child and family data, developmental history, pregnancy and birth, health, and school.

During intervention

  • Assessments: every time a protocol is administered, with date and responsible party.
  • Intervention plan: goals, targets, steps, mastery criteria, and responsible parties, including versions over time.
  • Session data collection: what was worked on, collected data, and observations. In most health professions, this record is part of the medical file, which has storage and confidentiality rules defined by the board.
  • Supervision notes and meeting minutes: decisions, referrals, and attendees.

Reports for third parties

  • Progress report: for the family, school, or doctor, covering the period, goals addressed, and results.
  • Reports for health insurance: many providers require periodic reports with plans and progress to maintain session authorization. Verify the format and frequency requested by the provider.

Write reports in clear language, with data and dates, and without exposing information not necessary for the recipient.

Health data and privacy

Information about a child's health and development is sensitive data. Basic precautions:

  • Collect only what is necessary and state what it will be used for.
  • Restrict access to those caring for the child.
  • Avoid sending documents via informal unprotected channels.
  • Have a privacy policy and know how to respond when the family requests access or correction of data.

Organization in Proaba

In Proaba, the child profile gathers registration, the intake history filled out by the family, assessments, plans, sessions, notes, and uploaded files. Notes have their own visibility; each professional only accesses what their role permits, and plans, sessions, assessment maps, and charts can be exported to PDF to compile reports.