ABA Glossary

What is an EHR (Electronic Health Record)?

An electronic health record (EHR) is the digital record of a client's health information - demographics, diagnoses, assessments, treatment plans, session documentation, and authorizations - kept by a provider and governed by HIPAA.

In ABA the EHR holds the client's whole clinical story: intake and diagnosis, the initial assessment and treatment plan, session notes and supervision records, progress reports, and the authorizations covering the services being delivered.

Because it contains protected health information, it carries requirements a general business system doesn't - access controls, audit trails, secure storage and transmission, and a business associate agreement with any vendor that handles the data.

For most practices the EHR isn't a separate product but the clinical half of their practice management platform, so what a technician documents during a session lands in the same record that scheduling, reporting, and billing all draw from.

HIPAA obligations follow the data rather than the software category. A practice handling protected health information needs access controls that limit each user to what their role requires, audit logging of who viewed or changed a record, encryption in transit and at rest, and a signed business associate agreement with any vendor that stores or processes the data. A tool without a BAA is not usable for PHI regardless of how well it works.

Records also have to persist. Retention periods are set by state law and payer contracts rather than by convenience, and a record generally has to remain retrievable and intact for years after a client is discharged. That makes export and continuity real evaluation criteria: a practice that cannot get its records out of a system in a usable form has a compliance problem waiting for it at renewal.

General-purpose EHRs frequently fit ABA poorly. They tend to model brief encounters rather than long recurring sessions, and they rarely have anywhere structured to put programs, targets, trial-level results, prompt levels, or supervision records - which is how practices end up with the clinical record split between an EHR and a set of spreadsheets. Keeping documentation, data, and authorizations in one record is what avoids the reconciliation work that split creates.

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