Clinical documentation
Live todayComplete ADOS Reports, Child Assessments, and Plans of Care — with AI assist built for ABA centers
Draft structured clinical documentation, export payer-ready PDFs, align to Medicaid CCP 8F checklist standards, and send Plans of Care to parents for review and signature — all in one HIPAA-aware platform on Google Cloud.
What is ABA clinical documentation software?
ABA clinical documentation software creates, reviews, signs, and stores the clinical records a therapy center produces — the ADOS-2 report, the child assessment, the functional behavior assessment, and the Plan of Care with its behavior intervention plan. In TargetFlo these forms live on the client record, tie into the 9-stage intake pipeline, draft faster with Gemini, and route to guardians for e-signature in the portal. AI accelerates documentation; licensed clinicians review, edit, and sign every report.
- Google Cloud Platform
- BAA framework
- Encrypted in transit & at rest
- Audit logged
- Gemini — assistive only
Three clinical forms
From diagnostic report to signed treatment plan
Each form is structured, pre-filled from the record, assisted by Gemini, and exported to PDF. Together they cover the Diagnostics → FBA → POC stages of intake.
ADOS-2 Report
Pipeline: Diagnostics
Structured ADOS-2 report with consensus scoring tables, algorithm domains, and client/assessment metadata. Gemini compose assistant fills empty fields, refines sections, or drafts from context. PDF generation for the payer packet.
- Consensus scoring tables by module
- Algorithm domains: Social Affect, Restricted & Repetitive Behavior, comparison score
- Client and assessment metadata carried from the client record
Child Assessment
Pipeline: Diagnostics → FBA
Fourteen-section child assessment covering identifying information, developmental, medical, and educational history, behavior, communication, adaptive skills, and family context. AI assist and PDF export.
- 14 structured sections with prefill from the client record
- Developmental, medical, educational, and behavioral history
- AI assist per section — clinician reviews every suggestion
Plan of Care / BIP
Pipeline: POC → Authorization
Treatment plan with skill-acquisition goal tables, behavior reduction and Behavior Intervention Plan sections, caregiver training goals, and a clinician-first signature chain. Structure maps to the NC Medicaid CCP 8F checklist and Medicare treatment plan expectations.
- Goal tables with baseline, mastery criteria, and target dates
- Behavior reduction / BIP tables with function and replacement behavior
- Caregiver training goals and consent capture
Diagnostics to Enrolled
Documents move the referral
Clinical forms are not a separate system. They sit on the client record inside the intake pipeline, and completing or uploading them advances the referral.
- 01
Diagnostics
ADOS-2 report · Child assessment
Uploading or completing the ADOS-2 report can advance the referral.
- 02
FBA
Functional behavior assessment summary
FBA fields on the POC are the foundation for BIP tables.
- 03
POC
Plan of Care / BIP
Clinician signs, then guardian signs in the portal; stage completes.
- 04
Authorization
Authorization request from the POC
Physician verified → submitted → pending → authorized.
- 05
Enrolled
Signed packet on the client record
Ready for scheduling and service delivery.
Diagnostics, FBA, POC, and Authorization are four of the nine stages in the TargetFlo intake pipeline.
Gemini compose assistant
Live todayAI accelerates documentation. Clinicians review, edit, and sign.
The compose assistant works from the form schema and the context already on the record. It proposes; the clinician disposes. Three modes cover the moments where drafting is slow.
- Fill empty — Suggests content only for fields the clinician has left blank, using the form schema and client context. Existing text is never overwritten.
- Refine — Rewrites a selected field or section for clarity and completeness while preserving the clinician's meaning. Shown as a suggestion to accept or discard.
- Draft section — Drafts an entire section — for example behavioral observations — from context already in the record. The clinician edits before anything is saved.
Fill empty fill_empty
Suggests content only for fields the clinician has left blank, using the form schema and client context. Existing text is never overwritten.
Refine refine
Rewrites a selected field or section for clarity and completeness while preserving the clinician's meaning. Shown as a suggestion to accept or discard.
Draft section section
Drafts an entire section — for example behavioral observations — from context already in the record. The clinician edits before anything is saved.
The same Gemini integration powers fax OCR, broadcast compose, and course MCQ generation — see AI integrations.
Parent signature
Clinician signs first. Then the family.
Parents sign in to the TargetFlo Parent Portal to review the Plan of Care after the BCBA signs. The notification carries no PHI — only a portal link.
Step 1 · Clinician
BCBA completes and signs the Plan of Care
The POC is finished on the client record. The clinician reviews every section and signs. TargetFlo records pocClinicianSignedAt.
Step 2 · TargetFlo
Guardian is notified
An SMS or email tells the parent a document is ready in the portal. The message contains no PHI — only a portal link.
Step 3 · Guardian
Parent reviews the POC in the portal
The guardian signs in on a phone, reads the full Plan of Care, and can see who signed it and when.
Step 4 · Guardian
Attestation and e-signature
The parent confirms they have reviewed the plan, participated in planning, and consents to services, then signs. TargetFlo records pocSignedAt.
Step 5 · Staff
Intake advances; PDF is filed
Staff see both timestamps on the record. The signed PDF lands in the client's documents and the POC stage can complete, opening Pending Authorization.
Capabilities
What is in clinical documentation today
Everything below is live in the product, alongside scheduling, data collection, and claims.
ADOS-2 structured report
Consensus scoring tables, algorithm domains, and comparison score with narrative sections drafted or refined by Gemini and owned by the examiner.
14-section child assessment
Identifying information through clinical impressions, prefilled from the client record, with per-section AI assist and PDF export.
Plan of Care / BIP
Goal tables, behavior reduction and BIP sections, caregiver training goals, and a clinician-first signature chain aligned to NC CCP 8F.
Gemini compose assistant
Three modes — fill empty, refine, draft section — that propose text from the form schema and record context. Nothing saves until a clinician accepts.
PDF export
Payer-ready PDFs for every form, attached to the client's documents tab and available to the portal after signature.
Parent portal review & e-signature
Guardians receive a non-PHI notification, read the full POC, attest, and sign from a phone. pocClinicianSignedAt and pocSignedAt are recorded.
Pipeline integration
Forms live on the client record and tie into the 9-stage intake pipeline. Document uploads can advance referral status.
External provider portal
Volunteers and external doctors complete assigned ADOS, assessment, or POC forms behind consent gates — without seeing the rest of the record.
Google Cloud + Gemini
Production deployments run on Google Cloud Platform with BAAs where required; Gemini is configured for assistive use under healthcare privacy expectations.
How it works
Six steps from Diagnostics to Authorization
The sequence a clinical team follows in TargetFlo, and the sequence described in this page's HowTo schema.
- 01
Complete the ADOS-2 report at the Diagnostics stage
Open the ADOS-2 form on the client record. Metadata is pre-filled; enter consensus scores, draft observations with the compose assistant, review, and export the PDF. Uploading the report can advance the referral.
- 02
Complete the child assessment
Work through the 14 sections — history, communication, adaptive skills, behavior. Use AI assist to fill empty fields from context, then review every suggestion.
- 03
Document the FBA
Record target behaviors, operational definitions, and hypothesized function. These fields feed the Behavior Intervention Plan tables on the POC.
- 01
Write the Plan of Care / BIP
Build goal tables with baselines and mastery criteria, behavior reduction tables, caregiver training goals, and the medical necessity narrative. The internal 114-item CCP 8F checklist shows what is still missing.
- 02
Clinician signs, then the guardian signs in the portal
The BCBA signs first. The guardian is notified with a non-PHI message, reviews the plan on a phone, attests, and e-signs. Both timestamps are visible to staff.
- 03
Export the packet and move to Authorization
The signed POC PDF files to the client's documents. The POC stage completes and Pending Authorization opens with physician verification, submission, and approval sub-steps.
Payer standards
Built around what Medicaid and Medicare expect to see
The Plan of Care structure maps to NC Medicaid CCP 8F sections and the documentation elements common to Medicare ABA treatment plans. Structure supports completeness — it never guarantees approval.
NC Medicaid
CCP 8F Plan of Care requirements
An educational outline of the 114-item POC and reauthorization checklist by section — submission controls through discharge planning — and where each maps in TargetFlo.
Read the guideMedicare
ABA treatment plan documentation
Orders, medical necessity narrative, measurable goals, and CPT-aligned service descriptions (97151–97158) — and the disclaimer that payer rules vary by MAC and state.
Read the guideHIPAA and Google Cloud
TargetFlo is built on a HIPAA-aware architecture designed for protected health information. Production deployments use Google Cloud Platform for document storage, processing, and infrastructure, with Google AI (Gemini) for assistive features under configurations intended to support healthcare privacy requirements. Organizations execute appropriate Business Associate Agreements (BAAs) with Google Cloud where required. Access controls, audit logging, encryption in transit and at rest, and role-based permissions are core to the platform. AI features are assistive — clinicians review all clinical documentation before signature and submission.
Compliance posture depends on your deployment, BAAs, policies, and configuration. TargetFlo does not provide legal advice.
Details on hosting, BAAs, encryption, and audit controls: Google Cloud security · Security & compliance
FAQ
Frequently asked questions
Clinical documentation in TargetFlo
See clinical documentation on your own diagnostics flow
Book a 30-minute demo. We walk an ADOS-2 report, a child assessment, and a Plan of Care from the Diagnostics stage to a signed PDF in the parent portal.