SynthABA Data Dictionary

Version: 1.0.0 | Document Types: 25 | Disciplines: ABA, Psychotherapy, SLP, OT

How to Read This Dictionary

Each document type in the SynthABA dataset inherits fields from BaseSyntheticCase (the envelope) and includes a SyntheticPatientContext object. The type-specific fields are listed in each section below.

For every field table:

| Column | Meaning | |--------|---------| | Field | JSON property name | | Type | Data type (string, integer, number, boolean, array[T], object, or a named sub-model) | | Required | Whether the field must be present in every record | | Constraints | Validation rules: min/max values, string length bounds, regex patterns, enum choices, array size limits | | Description | What the field represents and how it should be used |

Fields marked with a default value are optional and will be auto-populated if omitted. Sub-models (e.g., BehaviorObservation, GoalProgress) are documented in Appendix A at the end of this document.

Global Enums

AgeBand

Patient age range bands used for de-identification.

| Value | Description | |-------|-------------| | 2-3 | Toddler / early childhood | | 4-5 | Preschool age | | 6-11 | School age | | 12-17 | Adolescent | | 18+ | Adult |

Sex

Biological sex for clinical context.

| Value | Description | |-------|-------------| | male | Male | | female | Female |

DiagnosisCode

ICD-10 diagnosis codes supported in the dataset.

| Value | Description | |-------|-------------| | F84.0 | Autistic disorder | | F84.1 | Atypical autism | | F84.5 | Asperger syndrome | | F90.0 | ADHD, predominantly inattentive type | | F90.2 | ADHD, combined type | | F70 | Mild intellectual disability | | F71 | Moderate intellectual disability | | F80.1 | Expressive language disorder | | F88 | Other disorders of psychological development |

Severity

Clinical severity level.

| Value | Description | |-------|-------------| | mild | Level 1 -- requires support | | moderate | Level 2 -- requires substantial support | | severe | Level 3 -- requires very substantial support |

InsurerId

Supported insurance payer identifiers.

| Value | Description | |-------|-------------| | uhc | UnitedHealthcare | | bcbs | Blue Cross Blue Shield | | aetna | Aetna | | cigna | Cigna | | tricare | TRICARE (military) | | medicaid_fl | Florida Medicaid |

SessionType

ABA session type classification.

| Value | Description | |-------|-------------| | dtt | Discrete Trial Training | | net | Natural Environment Teaching | | parent_training | Parent/caregiver training session | | social_skills | Social skills group or individual session | | supervision_direct | Direct supervision (BCBA observing RBT with client) | | supervision_indirect | Indirect supervision (case review, documentation review) |

BehaviorFunction

Four functions of behavior per ABA framework.

| Value | Description | |-------|-------------| | escape | Escape/avoidance of demands or stimuli | | attention | Access to social attention | | tangible | Access to tangible items or activities | | sensory | Automatic/sensory reinforcement |

CptCode (ABA)

ABA-specific CPT codes.

| Value | Description | |-------|-------------| | 97151 | Behavior identification assessment | | 97152 | Behavior identification supporting assessment | | 97153 | Adaptive behavior treatment by protocol (RBT) | | 97155 | Adaptive behavior treatment with protocol modification (BCBA) | | 97156 | Family adaptive behavior treatment guidance (caregiver training) |

CaseLanguage

Language of the generated case content.

| Value | Description | |-------|-------------| | en | English | | es | Spanish |

DifficultyLevel

Clinical complexity level for training/evaluation purposes.

| Value | Description | |-------|-------------| | basic | Straightforward presentation, single diagnosis | | intermediate | Moderate complexity, common comorbidities | | advanced | Complex presentation, multiple comorbidities | | expert | Highly complex, ambiguous, or atypical cases |

AssessmentTool

Standardized ABA assessment instruments.

| Value | Description | |-------|-------------| | vb_mapp | Verbal Behavior Milestones Assessment and Placement Program | | ablls_r | Assessment of Basic Language and Learning Skills -- Revised | | afls | Assessment of Functional Living Skills | | vineland_3 | Vineland Adaptive Behavior Scales, Third Edition | | ados_2 | Autism Diagnostic Observation Schedule, Second Edition | | peak | Promoting the Emergence of Advanced Knowledge | | essentials_for_living | Essentials for Living |

AssessmentDomain

Domains assessed in ABA evaluations.

| Value | Description | |-------|-------------| | communication | Verbal and nonverbal communication skills | | social_skills | Social interaction and relationship skills | | adaptive_behavior | Daily living and adaptive functioning | | challenging_behavior | Maladaptive or interfering behaviors | | academic_skills | Academic readiness and performance | | play_leisure | Play skills and leisure activities | | self_care | Self-care and personal hygiene | | motor_skills | Fine and gross motor skills |

TrialType

Type of learning trial in session data collection.

| Value | Description | |-------|-------------| | dtt | Discrete Trial Training | | net | Natural Environment Teaching | | incidental | Incidental teaching | | free_operant | Free operant observation |

DataCollectionMethod

Method used to collect behavioral data.

| Value | Description | |-------|-------------| | frequency | Frequency/event recording | | duration | Duration recording | | latency | Latency recording | | interval | Interval recording (whole/partial) | | permanent_product | Permanent product recording | | abc_narrative | ABC narrative recording |

SupervisionType

Type of BCBA supervision session.

| Value | Description | |-------|-------------| | direct_observation | Direct observation of supervisee with client | | indirect_review | Indirect review (documentation, case discussion) | | group_supervision | Group supervision meeting | | individual_meeting | Individual supervision meeting |

DischargeReason

Reason for discharge from ABA services.

| Value | Description | |-------|-------------| | goals_met | Treatment goals achieved | | family_request | Family-initiated discharge | | aging_out | Client aged out of services | | relocation | Family relocated | | insurance_exhausted | Insurance benefits exhausted | | lack_of_progress | Insufficient progress despite modifications | | noncompliance | Chronic noncompliance with treatment | | transition_to_school | Transitioned to school-based services |

Base Schema (All Records)

Class: BaseSyntheticCase Description: Every synthetic case must have this envelope. These fields appear in all 25 document types.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | case_id | string | Yes | -- | Auto-generated UUID | | case_type | string | Yes | -- | Document type identifier (e.g., soap_note, assessment_section, abc_data) | | language | CaseLanguage | No | Default: en | Language of the generated content | | difficulty | DifficultyLevel | No | Default: intermediate | Clinical complexity level | | patient_context | SyntheticPatientContext | Yes | -- | De-identified patient demographic and clinical context | | generated_by | string | No | Default: synthaba_cloud | Generator system identifier | | generator_version | string | No | Default: 1.0.0 | Generator software version | | template_version | string | No | Default: 1.0.0 | Template version used for generation | | synthetic | boolean | No | Default: true | Flag confirming this is synthetic data | | vlayer_ready | boolean | No | Default: true | Whether the record is ready for VLayer validation | | vlayer_source_type | string | No | Default: synthetic | VLayer source classification | | vlayer_expected_classification | string | No | Default: synthetic_candidate | Expected VLayer classification result |

Patient Context

Class: SyntheticPatientContext Description: De-identified patient context. No real PHI by design. Embedded in every record's patient_context field.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | age_band | AgeBand | Yes | -- | Patient age range band | | sex | Sex | Yes | -- | Biological sex | | diagnosis_codes | array[DiagnosisCode] | Yes | -- | ICD-10 diagnosis codes | | severity | Severity | Yes | -- | Clinical severity level | | comorbidities | array[string] | No | -- | E.g., "speech delay", "sensory processing" | | insurer | InsurerId | Yes | -- | Insurance payer identifier | | authorized_hours_weekly | number | Yes | -- | Authorized weekly treatment hours | | months_in_treatment | integer | Yes | -- | Duration of treatment in months | | setting | string | Yes | Enum: clinic, home, school, telehealth | Treatment setting | | patient_label | string | No | Default: Client_A000 | Synthetic patient identifier (not PHI) | | medications | array[string] | No | -- | Current medications |

CPT Code Reference

| Code | Description | Discipline | Provider | |------|-------------|------------|----------| | 97151 | Behavior identification assessment | ABA | BCBA | | 97152 | Behavior identification supporting assessment | ABA | BCBA | | 97153 | Adaptive behavior treatment by protocol | ABA | RBT | | 97155 | Adaptive behavior treatment with protocol modification | ABA | BCBA | | 97156 | Family adaptive behavior treatment guidance | ABA | BCBA | | 90834 | Psychotherapy, 45 minutes | Psychotherapy | Therapist | | 90837 | Psychotherapy, 60 minutes | Psychotherapy | Therapist | | 90847 | Family psychotherapy, conjoint | Psychotherapy | Therapist | | 90853 | Group psychotherapy | Psychotherapy | Therapist | | 96130 | Psychological testing evaluation by psychologist, first hour | Psychotherapy | Psychologist | | 96131 | Psychological testing evaluation by psychologist, additional hour | Psychotherapy | Psychologist | | 96132 | Neuropsychological testing evaluation by psychologist, first hour | Psychotherapy | Psychologist | | 96133 | Neuropsychological testing evaluation by psychologist, additional hour | Psychotherapy | Psychologist | | 92507 | Speech-language treatment, individual | SLP | SLP | | 92508 | Speech-language treatment, group | SLP | SLP | | 92521 | Evaluation of speech fluency | SLP | SLP | | 92522 | Evaluation of speech sound production | SLP | SLP | | 92523 | Evaluation of speech sound production with language comprehension/expression | SLP | SLP | | 92524 | Behavioral and qualitative analysis of voice and resonance | SLP | SLP | | 97165 | OT evaluation, low complexity | OT | OT | | 97166 | OT evaluation, moderate complexity | OT | OT | | 97167 | OT evaluation, high complexity | OT | OT | | 97168 | OT re-evaluation | OT | OT | | 97530 | Therapeutic activities, direct patient contact | OT | OT | | 97533 | Sensory integrative techniques | OT | OT |

ICD-10 Code Reference

| Code | Description | |------|-------------| | F84.0 | Autistic disorder (Childhood autism) | | F84.1 | Atypical autism | | F84.5 | Asperger syndrome | | F90.0 | Attention-deficit hyperactivity disorder, predominantly inattentive type | | F90.2 | Attention-deficit hyperactivity disorder, combined type | | F70 | Mild intellectual disability | | F71 | Moderate intellectual disability | | F80.1 | Expressive language disorder | | F88 | Other disorders of psychological development |

ABA Documents (10)

soap_note -- SOAP Note

Class: SyntheticSOAPNote
Description: Subjective-Objective-Assessment-Plan clinical note for ABA therapy sessions. Documents behavioral observations, quantitative data, clinical interpretation, and next-session planning.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | session_type | SessionType | Yes | -- | Type of ABA session conducted | | session_duration_minutes | integer | Yes | Min: 15, Max: 180 | Duration of session in minutes | | cpt_code | CptCode | Yes | -- | CPT billing code for session | | provider_role | string | Yes | Enum: rbt, bcba | Role of the service provider | | subjective | string | Yes | MinLen: 10, MaxLen: 5000 | Client presentation, caregiver report, environmental context. 2-4 sentences. Use ABA terminology. | | objective | string | Yes | MinLen: 10, MaxLen: 5000 | Quantitative behavioral data. Frequency, duration, intensity. Include specific numbers. Reference target behaviors from treatment plan. | | assessment | string | Yes | MinLen: 10, MaxLen: 3000 | Clinical interpretation of data. Progress toward goals. Compare to baseline. Note trends. Use behavior analytic language. | | plan | string | Yes | MinLen: 10, MaxLen: 3000 | Next steps. Modifications to protocol if needed. Goals to target next session. Caregiver recommendations. | | behaviors_observed | array[BehaviorObservation] | Yes | MinItems: 1, MaxItems: 20 | Behavioral observations recorded during session | | goals_addressed | array[GoalProgress] | Yes | MinItems: 1, MaxItems: 20 | Goals targeted and progress data for each |

abc_data -- ABC Data Record

Class: SyntheticABCRecord
Description: Antecedent-Behavior-Consequence data collection record. Captures detailed behavioral events during a session for functional behavior analysis.

treatment_goals -- Treatment Goals

Class: SyntheticTreatmentGoals
Description: Treatment goal documentation for ABA services. Includes SMART goals with baselines, targets, and medical necessity justification for insurer review.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | assessment_type | string | Yes | Enum: initial, reassessment | Whether this is an initial assessment or reassessment | | recommended_hours_weekly | number | Yes | Min: 0.5, Max: 40.0 | Recommended weekly treatment hours | | goals | array[TreatmentGoal] | Yes | MinItems: 1, MaxItems: 20 | Treatment goals with baselines and targets | | medical_necessity_summary | string | Yes | MinLen: 20, MaxLen: 5000 | Clinical justification for services. Reference diagnosis, severity, functional limitations. Written for insurer review. |

insurance_auth -- Insurance Authorization

Class: SyntheticInsuranceAuth
Description: Insurance authorization request document. Contains clinical rationale, goal summaries, service utilization data, and hours justification formatted for insurer review.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | auth_type | string | Yes | Enum: initial, reauthorization | Authorization type | | insurer | InsurerId | Yes | -- | Target insurance payer | | diagnosis_code | DiagnosisCode | Yes | -- | Primary ICD-10 diagnosis code | | clinical_rationale | string | Yes | MinLen: 20, MaxLen: 5000 | Medical necessity justification. Insurer-specific language. Reference functional limitations and treatment progress. | | goals_summary | array[GoalSummaryForInsurer] | Yes | MinItems: 1, MaxItems: 20 | Goal progress summaries formatted for insurer | | service_summary | ServiceSummary | Yes | -- | Service utilization summary | | hours_requested | number | Yes | Min: 0.5, Max: 40.0 | Weekly hours requested | | hours_justification | string | Yes | MinLen: 10, MaxLen: 3000 | Justification for requested hours |

crisis_plan -- Crisis Plan

Class: SyntheticCrisisPlan
Description: Behavioral crisis intervention plan using a green-yellow-red tiered strategy model. Documents crisis behaviors, precursors, prevention strategies, de-escalation protocols, and emergency procedures.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | target_crisis_behaviors | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | Behaviors that constitute a crisis (e.g., SIB, aggression, elopement) | | precursor_behaviors | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | Behaviors that precede crisis (early warning signs) | | green_strategies | array[string] | Yes | MinItems: 1, MaxItems: 8; item MinLen: 10, MaxLen: 500 | Prevention strategies when client is calm | | yellow_strategies | array[string] | Yes | MinItems: 1, MaxItems: 8; item MinLen: 10, MaxLen: 500 | De-escalation strategies for precursor behaviors | | red_strategies | array[string] | Yes | MinItems: 1, MaxItems: 8; item MinLen: 10, MaxLen: 500 | Safety strategies during active crisis | | post_crisis_protocol | string | Yes | MinLen: 20, MaxLen: 2000 | Steps after crisis resolves (debriefing, documentation, care) | | restrictive_procedures | array[string] or null | No | Default: null; item MaxLen: 500 | Any restrictive procedures authorized (if applicable) | | emergency_contacts | string | Yes | MinLen: 10, MaxLen: 500 | Who to contact in emergency (roles, not real names/numbers) | | medical_considerations | string or null | No | Default: null; MaxLen: 1000 | Medications, seizure risk, physical limitations | | review_date | string | Yes | MaxLen: 10, Pattern: ^\d{4}-\d{2}-\d{2}$ | Plan review date in YYYY-MM-DD format |

supervision_note -- Supervision Note

Class: SyntheticSupervisionNote
Description: BCBA supervision documentation for RBT/trainee oversight. Tracks skills observed, feedback provided, competency ratings, and BACB fieldwork compliance.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | supervision_type | SupervisionType | Yes | -- | Type of supervision session | | supervisee_role | string | Yes | Enum: rbt, bcaba, bcba_trainee | Role of the supervisee | | supervision_duration_minutes | integer | Yes | Min: 15, Max: 240 | Duration of supervision in minutes | | cpt_code | string | Yes | Enum: 97155, 97156 | 97155=adaptive supervision, 97156=caregiver training with supervision | | skills_observed | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 10, MaxLen: 500 | Specific skills the supervisee demonstrated | | feedback_provided | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 10, MaxLen: 500 | Specific corrective and positive feedback given | | competency_rating | string | Yes | Enum: below_expectations, meets_expectations, exceeds_expectations | Supervisee competency rating | | client_progress_notes | string | Yes | MinLen: 20, MaxLen: 3000 | Clinical observations about client during supervised session | | treatment_modifications | array[string] or null | No | Default: null; item MaxLen: 500 | Any protocol changes recommended based on observation | | supervision_hours_accrued | number | Yes | Min: 0.25, Max: 8.0 | Supervision hours accrued for BACB requirements | | meets_bacb_requirements | boolean | Yes | -- | Whether this session meets BACB fieldwork standards | | next_supervision_focus | string | Yes | MinLen: 10, MaxLen: 500 | Focus area for next supervision session |

discharge_summary -- Discharge Summary

Class: SyntheticDischargeSummary
Description: End-of-treatment summary documenting treatment course, outcomes, goal attainment, assessment score changes, and post-discharge recommendations.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | discharge_reason | DischargeReason | Yes | -- | Reason for discharge | | treatment_duration_months | integer | Yes | Min: 1, Max: 120 | Total treatment duration in months | | total_sessions_provided | integer | Yes | Min: 1, Max: 5000 | Total number of sessions delivered | | goals_summary | array[object] | Yes | MinItems: 1, MaxItems: 20 | Each goal with: name, baseline, final_value, status (met/partially_met/not_met) | | assessment_scores_initial | object | Yes | -- | Initial assessment scores (VB-MAPP, ABLLS-R, Vineland, etc.) | | assessment_scores_final | object | Yes | -- | Final assessment scores at discharge | | clinical_summary | string | Yes | MinLen: 50, MaxLen: 5000 | Narrative summary of treatment course and outcomes | | recommendations | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 10, MaxLen: 500 | Post-discharge recommendations (school support, follow-up, etc.) | | referrals | array[string] or null | No | Default: null; item MaxLen: 300 | Referrals to other providers (OT, SLP, psych) | | caregiver_training_completed | array[string] | No | Item MaxLen: 300 | Parent training modules completed during treatment |

progress_report -- Progress Report

Class: SyntheticProgressReport
Description: Periodic progress report for continued authorization. Documents sessions delivered, goal progress, behavior trends, intervention effectiveness, and justification for continued services.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | reporting_period_start | string | Yes | MaxLen: 10, Pattern: ^\d{4}-\d{2}-\d{2}$ | Reporting period start date | | reporting_period_end | string | Yes | MaxLen: 10, Pattern: ^\d{4}-\d{2}-\d{2}$ | Reporting period end date | | sessions_authorized | integer | Yes | Min: 1, Max: 1000 | Number of sessions authorized | | sessions_delivered | integer | Yes | Min: 0, Max: 1000 | Number of sessions actually delivered | | attendance_rate | number | Yes | Min: 0.0, Max: 1.0 | Attendance rate as decimal (e.g., 0.85 = 85%) | | goals_progress | array[object] | Yes | MinItems: 1, MaxItems: 20 | Each goal with: name, baseline, current_value, target, trend | | behavior_data_summary | string | Yes | MinLen: 50, MaxLen: 3000 | Summary of behavior data trends across reporting period | | intervention_effectiveness | string | Yes | MinLen: 50, MaxLen: 3000 | Analysis of which interventions are working and which need modification | | recommended_hours_next_period | number | Yes | Min: 0.5, Max: 40.0 | Recommended weekly hours for next period | | recommended_duration_months | integer | Yes | Min: 1, Max: 12 | Recommended duration for next authorization period | | justification | string | Yes | MinLen: 50, MaxLen: 3000 | Medical necessity justification for continued services | | new_goals_proposed | array[object] or null | No | Default: null | New goals to add for next authorization period | | goals_to_discontinue | array[string] or null | No | Default: null | Goals to remove (met or no longer appropriate) |

session_data -- Session Trial Data

Class: SyntheticSessionData
Description: Granular trial-by-trial data collection record for skill acquisition programs. Captures individual trial outcomes, prompt levels, reinforcement schedules, and mastery criteria.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | trial_type | TrialType | Yes | -- | Type of learning trial | | data_collection_method | DataCollectionMethod | Yes | -- | Method used for data collection | | trials | array[object] | Yes | MinItems: 1, MaxItems: 200 | Each trial: target, stimulus, response (correct/incorrect/prompted), prompt_level, notes | | total_trials | integer | Yes | Min: 1, Max: 200 | Total number of trials conducted | | correct_independent | integer | Yes | Min: 0, Max: 200 | Number of correct independent responses | | correct_prompted | integer | Yes | Min: 0, Max: 200 | Number of correct prompted responses | | incorrect | integer | Yes | Min: 0, Max: 200 | Number of incorrect responses | | no_response | integer | Yes | Min: 0, Max: 200 | Number of no-response trials | | accuracy_percentage | number | Yes | Min: 0.0, Max: 100.0 | Overall accuracy percentage | | prompt_levels_used | array[string] | Yes | MinItems: 1, MaxItems: 8; Enum per item: full_physical, partial_physical, model, gestural, positional, verbal, visual, independent | Prompt levels used during session | | reinforcers_used | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 2, MaxLen: 200 | Reinforcers delivered during session | | reinforcement_schedule | string | Yes | MinLen: 3, MaxLen: 100 | Schedule of reinforcement (e.g., VR3, FR1, VI30s, DRO 5min) | | mastery_criterion | string | Yes | MinLen: 10, MaxLen: 300 | Mastery criterion (e.g., 80% independent across 3 consecutive sessions) | | mastery_met | boolean | Yes | -- | Whether mastery criterion was met this session |

assessment_section -- Assessment Section

Class: SyntheticAssessmentSection
Description: Standardized assessment results for a specific domain. Documents scores, clinical observations, strengths, areas of need, and recommended goals based on formal assessment tool administration.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | assessment_tool | AssessmentTool | Yes | -- | Standardized assessment instrument used | | assessment_domain | AssessmentDomain | Yes | -- | Domain being assessed | | assessment_type | string | Yes | Enum: initial, reassessment | Initial or reassessment | | scores | object | Yes | -- | Domain scores: raw_score, age_equivalent, standard_score, percentile | | previous_scores | object or null | No | Default: null | Scores from prior assessment (for reassessment comparison) | | clinical_observations | string | Yes | MinLen: 50, MaxLen: 3000 | Narrative observations during assessment administration | | strengths_identified | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 10, MaxLen: 500 | Client strengths observed | | areas_of_need | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 10, MaxLen: 500 | Areas requiring intervention | | recommended_goals | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 10, MaxLen: 500 | Goals recommended based on assessment | | medical_necessity_statement | string | Yes | MinLen: 50, MaxLen: 2000 | Justification for ABA services based on assessment results |

Psychotherapy Documents (8)

psychotherapy_note -- Psychotherapy Session Note

Class: SyntheticPsychotherapyNote
Description: Individual psychotherapy session documentation. Covers presenting problem, mental status, therapeutic interventions, client response, risk assessment, and treatment planning.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | session_type | string | Yes | Enum: individual, couples, family | Type of therapy session | | modality | string | Yes | Enum: cbt, dbt, emdr, psychodynamic, motivational_interviewing | Therapeutic modality used | | session_duration_minutes | integer | Yes | Min: 45, Max: 60 | Session duration in minutes | | cpt_code | string | Yes | Enum: 90834, 90837 | 90834=45-min psychotherapy, 90837=60-min psychotherapy | | presenting_problem | string | Yes | MinLen: 10, MaxLen: 3000 | Current presenting problem and reason for session | | mental_status_brief | string | Yes | MinLen: 10, MaxLen: 2000 | Brief mental status observations (appearance, mood, affect) | | interventions_used | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | Therapeutic interventions applied during session | | client_response | string | Yes | MinLen: 10, MaxLen: 3000 | Client response to interventions and engagement level | | risk_assessment | string | Yes | MinLen: 10, MaxLen: 2000 | Suicidality, homicidality, self-harm risk evaluation | | plan | string | Yes | MinLen: 10, MaxLen: 3000 | Treatment plan updates, next session focus, referrals | | homework_assigned | string or null | No | Default: null; MaxLen: 1000 | Between-session assignments or exercises | | progress_toward_goals | string | Yes | MinLen: 10, MaxLen: 3000 | Progress toward established treatment goals |

psychiatric_eval -- Psychiatric Evaluation

Class: SyntheticPsychiatricEval
Description: Comprehensive psychiatric evaluation including history of present illness, psychiatric/medical/family/social history, substance use, full mental status exam, diagnoses, and medication management.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | chief_complaint | string | Yes | MinLen: 10, MaxLen: 2000 | Patient's primary reason for seeking evaluation | | history_present_illness | string | Yes | MinLen: 20, MaxLen: 5000 | Detailed history of current psychiatric symptoms and timeline | | psychiatric_history | string | Yes | MinLen: 10, MaxLen: 3000 | Past psychiatric diagnoses, hospitalizations, treatments | | medical_history | string | Yes | MinLen: 10, MaxLen: 3000 | Relevant medical conditions and surgical history | | family_history | string | Yes | MinLen: 10, MaxLen: 3000 | Family psychiatric and medical history | | social_history | string | Yes | MinLen: 10, MaxLen: 3000 | Living situation, education, employment, relationships | | substance_use_history | string | Yes | MinLen: 10, MaxLen: 3000 | Alcohol, tobacco, illicit substance use history | | mental_status_exam | string | Yes | MinLen: 20, MaxLen: 5000 | Full mental status examination findings | | diagnoses | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 300 | Diagnoses with ICD-10 codes (e.g., "F32.1 Major depressive disorder, moderate") | | risk_assessment | string | Yes | MinLen: 10, MaxLen: 3000 | Suicide risk, violence risk, self-harm assessment | | treatment_recommendations | string | Yes | MinLen: 10, MaxLen: 3000 | Recommended treatment plan including therapy and medication | | medications_prescribed | array[string] | Yes | MinItems: 0, MaxItems: 15; item MinLen: 3, MaxLen: 300 | Medications prescribed with dosage and frequency | | follow_up_plan | string | Yes | MinLen: 10, MaxLen: 2000 | Follow-up appointment timeline and monitoring plan |

mental_status_exam -- Mental Status Exam

Class: SyntheticMentalStatusExam
Description: Structured mental status examination documenting all standard MSE domains: appearance, behavior, speech, mood/affect, thought process/content, perceptions, cognition, insight, and judgment.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | appearance | string | Yes | MinLen: 10, MaxLen: 1000 | General appearance, grooming, hygiene, attire, psychomotor activity | | behavior | string | Yes | MinLen: 10, MaxLen: 1000 | Eye contact, cooperation, agitation, mannerisms, psychomotor changes | | speech | string | Yes | MinLen: 10, MaxLen: 1000 | Rate, rhythm, volume, tone, spontaneity, latency | | mood_reported | string | Yes | MinLen: 3, MaxLen: 500 | Patient's self-reported mood in their own words | | affect_observed | string | Yes | MinLen: 5, MaxLen: 1000 | Observed affect -- range, congruence, reactivity, intensity | | thought_process | string | Yes | MinLen: 10, MaxLen: 1000 | Logical, linear, tangential, circumstantial, loose associations, flight of ideas | | thought_content | string | Yes | MinLen: 10, MaxLen: 1000 | Delusions, obsessions, phobias, suicidal/homicidal ideation | | perceptions | string | Yes | MinLen: 5, MaxLen: 1000 | Hallucinations (auditory, visual), illusions, depersonalization | | cognition | string | Yes | MinLen: 10, MaxLen: 1000 | Orientation, attention, concentration, memory, abstract thinking | | insight | string | Yes | MinLen: 5, MaxLen: 500 | Patient's awareness of illness and need for treatment | | judgment | string | Yes | MinLen: 5, MaxLen: 500 | Decision-making capacity and appropriateness | | overall_impression | string | Yes | MinLen: 10, MaxLen: 2000 | Clinician summary impression integrating all MSE domains |

safety_plan -- Safety Plan

Class: SyntheticSafetyPlan
Description: Stanley-Brown Safety Planning Intervention document. Structured six-step crisis plan for patients at risk of self-harm, including warning signs, coping strategies, social supports, professional resources, and means restriction.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | warning_signs | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | Internal cues that a crisis may be developing (thoughts, images, mood, behaviors) | | coping_strategies | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | Things the patient can do without contacting another person | | social_contacts_for_distraction | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | People and social settings that provide distraction | | family_or_friends_for_help | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | Family members or friends who can help during a crisis | | professional_resources | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | Clinicians, agencies, crisis lines to contact | | means_restriction_plan | string | Yes | MinLen: 10, MaxLen: 2000 | Steps to make environment safer by restricting access to lethal means | | reasons_for_living | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | Patient-identified reasons for living | | emergency_contacts | string | Yes | MinLen: 10, MaxLen: 1000 | Emergency contact roles and resources (988 Lifeline, local crisis, ER) | | clinician_follow_up_plan | string | Yes | MinLen: 10, MaxLen: 2000 | Clinician plan for monitoring and follow-up after safety plan creation |

group_therapy_note -- Group Therapy Note

Class: SyntheticGroupTherapyNote
Description: Group psychotherapy session documentation. Captures group dynamics, member participation, facilitator observations, interventions used, and next-session planning.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | group_name | string | Yes | MinLen: 3, MaxLen: 200 | Name of the therapy group (e.g., "DBT Skills Group", "Grief Support") | | group_type | string | Yes | Enum: process, psychoeducational, skills_training, support | Type of therapy group | | session_number | integer | Yes | Min: 1, Max: 999 | Sequential session number | | cpt_code | string | No | Default: 90853 | Group psychotherapy CPT code | | session_duration_minutes | integer | Yes | Min: 60, Max: 120 | Session duration in minutes | | topic | string | Yes | MinLen: 5, MaxLen: 500 | Primary topic or theme addressed in session | | facilitator_observations | string | Yes | MinLen: 10, MaxLen: 3000 | Facilitator clinical observations about group process | | group_dynamics | string | Yes | MinLen: 10, MaxLen: 3000 | Interpersonal dynamics, cohesion, conflict, engagement patterns | | member_participation_summary | string | Yes | MinLen: 10, MaxLen: 3000 | Summary of member participation levels and notable contributions | | interventions_used | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | Therapeutic interventions applied during group session | | plan_next_session | string | Yes | MinLen: 10, MaxLen: 2000 | Planned topic, activities, and goals for next session |

family_therapy_note -- Family Therapy Note

Class: SyntheticFamilyTherapyNote
Description: Conjoint family therapy session documentation. Covers family dynamics, presenting issues, therapeutic interventions, family response, and progress toward family therapy goals.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | cpt_code | string | No | Default: 90847 | Family psychotherapy CPT code | | session_duration_minutes | integer | Yes | Min: 45, Max: 90 | Session duration in minutes | | family_members_present | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 3, MaxLen: 200 | Roles of family members present (e.g., "Mother", "Adolescent client", "Stepfather") | | presenting_issues | string | Yes | MinLen: 10, MaxLen: 3000 | Current presenting issues and session focus | | family_dynamics_observed | string | Yes | MinLen: 10, MaxLen: 3000 | Observed communication patterns, alliances, boundaries, conflict styles | | interventions_used | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | Therapeutic interventions applied (e.g., structural, strategic, narrative) | | family_response | string | Yes | MinLen: 10, MaxLen: 3000 | Family response to interventions and engagement level | | homework_assigned | string or null | No | Default: null; MaxLen: 1000 | Between-session assignments for the family | | progress_toward_goals | string | Yes | MinLen: 10, MaxLen: 3000 | Progress toward established family therapy goals | | plan | string | Yes | MinLen: 10, MaxLen: 3000 | Next steps, session focus for next appointment, referrals |

psychological_testing -- Psychological Testing

Class: SyntheticPsychologicalTesting
Description: Comprehensive psychological testing report. Documents referral reason, tests administered, behavioral observations, cognitive and emotional results, diagnostic impressions, and clinical recommendations.

substance_abuse_assessment -- Substance Abuse Assessment

Class: SyntheticSubstanceAbuseAssessment
Description: Substance use disorder assessment using DSM-5 criteria. Documents substance history, withdrawal, treatment history, screening tools, motivation stage, severity level, and treatment recommendations.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | substances_reported | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 3, MaxLen: 200 | Substances reported by patient (e.g., "Alcohol", "Cannabis", "Opioids") | | age_of_onset | integer | Yes | Min: 8, Max: 65 | Age of first substance use | | use_frequency | string | Yes | MinLen: 5, MaxLen: 500 | Current frequency and pattern of use | | last_use | string | Yes | MinLen: 3, MaxLen: 200 | Date or timeframe of most recent use | | withdrawal_history | string | Yes | MinLen: 10, MaxLen: 2000 | History of withdrawal symptoms, seizures, DTs, medical complications | | treatment_history | string | Yes | MinLen: 10, MaxLen: 3000 | Previous substance abuse treatment episodes and outcomes | | motivation_level | string | Yes | Enum: precontemplation, contemplation, preparation, action, maintenance | Stage of change per Prochaska transtheoretical model | | screening_tools_used | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 3, MaxLen: 200 | Screening instruments used (e.g., AUDIT, DAST-10, CAGE, CIWA-Ar) | | dsm5_criteria_met | integer | Yes | Min: 0, Max: 11 | Number of DSM-5 substance use disorder criteria met | | severity_level | string | Yes | Enum: mild, moderate, severe | DSM-5 severity: mild (2-3), moderate (4-5), severe (6+) | | recommendations | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 10, MaxLen: 500 | Treatment recommendations (e.g., IOP, residential, MAT) | | referrals | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 5, MaxLen: 500 | Referrals made (e.g., detox, psychiatry, AA/NA, housing) |

Speech-Language Pathology Documents (4)

slp_evaluation -- SLP Evaluation

Class: SyntheticSLPEvaluation
Description: Comprehensive speech-language pathology evaluation. Documents oral mechanism exam, articulation, receptive/expressive language, pragmatics, standardized test results, diagnoses, and treatment recommendations.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | cpt_codes_used | array[string] | Yes | MinItems: 1, MaxItems: 4; Enum per item: 92521, 92522, 92523, 92524 | SLP evaluation CPT codes used | | referral_reason | string | Yes | MinLen: 10, MaxLen: 2000 | Reason for referral to speech-language pathology services | | case_history | string | Yes | MinLen: 20, MaxLen: 5000 | Developmental, medical, and communication history | | oral_mechanism_exam | string | Yes | MinLen: 10, MaxLen: 3000 | Oral-motor structure and function examination findings | | articulation_assessment | string | Yes | MinLen: 10, MaxLen: 3000 | Speech sound production assessment results | | language_comprehension | string | Yes | MinLen: 10, MaxLen: 3000 | Receptive language assessment findings | | language_expression | string | Yes | MinLen: 10, MaxLen: 3000 | Expressive language assessment findings | | fluency_assessment | string or null | No | Default: null; MinLen: 10, MaxLen: 3000 | Fluency/stuttering assessment findings if applicable | | voice_assessment | string or null | No | Default: null; MinLen: 10, MaxLen: 3000 | Voice quality assessment findings if applicable | | pragmatic_language | string | Yes | MinLen: 10, MaxLen: 3000 | Social communication and pragmatic language skills | | standardized_tests | array[string] | Yes | MinItems: 1, MaxItems: 20; item MinLen: 3, MaxLen: 200 | Standardized assessments administered (e.g., CELF-5, PLS-5, GFTA-3) | | test_results_summary | string | Yes | MinLen: 20, MaxLen: 5000 | Summary of standardized test scores and interpretation | | clinical_impressions | string | Yes | MinLen: 20, MaxLen: 3000 | Clinician's overall impressions and diagnostic formulation | | diagnoses | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 3, MaxLen: 200 | Speech-language diagnoses (e.g., "F80.1 Expressive language disorder") | | recommendations | array[string] | Yes | MinItems: 1, MaxItems: 15; item MinLen: 5, MaxLen: 500 | Treatment recommendations and referrals | | treatment_frequency | string | Yes | MinLen: 5, MaxLen: 100 | Recommended treatment frequency (e.g., 2x/week x 30 min) |

slp_session_note -- SLP Session Note

Class: SyntheticSLPSessionNote
Description: Speech-language therapy session note. Documents treatment targets, activities, cueing hierarchy, accuracy data, client response, and next-session planning.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | cpt_code | string | No | Default: 92507 | SLP treatment CPT code | | session_duration_minutes | integer | Yes | Min: 15, Max: 60 | Session duration in minutes | | session_type | string | Yes | Enum: individual, group | Individual or group therapy session | | treatment_targets | array[string] | Yes | MinItems: 1, MaxItems: 15; item MinLen: 3, MaxLen: 500 | Specific treatment targets addressed in session | | activities_used | array[string] | Yes | MinItems: 1, MaxItems: 15; item MinLen: 3, MaxLen: 500 | Therapeutic activities and materials used | | cueing_hierarchy | string | Yes | MinLen: 5, MaxLen: 500 | Type and level of cueing provided (e.g., minimal verbal cues, moderate tactile cues) | | accuracy_data | string | Yes | MinLen: 5, MaxLen: 1000 | Quantitative accuracy data with percentages (e.g., 80% accuracy for /r/ in initial position) | | client_response | string | Yes | MinLen: 10, MaxLen: 3000 | Client's response to treatment, engagement, and behavior | | modifications_made | string or null | No | Default: null; MinLen: 5, MaxLen: 1000 | Any modifications to treatment approach during session | | home_practice_assigned | string or null | No | Default: null; MinLen: 5, MaxLen: 1000 | Home practice activities assigned to client/caregiver | | plan | string | Yes | MinLen: 10, MaxLen: 3000 | Plan for next session including targets and strategies |

slp_progress_report -- SLP Progress Report

Class: SyntheticSLPProgressReport
Description: Periodic speech-language therapy progress report. Documents attendance, goal progress, functional communication status, areas of progress and concern, and justification for continued services.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | reporting_period | string | Yes | MinLen: 5, MaxLen: 100 | Reporting period (e.g., "January 2026 - March 2026") | | sessions_attended | integer | Yes | Min: 0, Max: 500 | Number of sessions attended | | sessions_scheduled | integer | Yes | Min: 1, Max: 500 | Number of sessions scheduled | | current_goals | array[GoalProgress] | Yes | MinItems: 1, MaxItems: 20 | Current treatment goals with progress data | | standardized_scores_comparison | string or null | No | Default: null; MinLen: 10, MaxLen: 3000 | Comparison of standardized scores from initial to current | | functional_communication_status | string | Yes | MinLen: 10, MaxLen: 3000 | Current functional communication abilities in daily contexts | | areas_of_progress | array[string] | Yes | MinItems: 1, MaxItems: 15; item MinLen: 5, MaxLen: 500 | Specific areas where client has demonstrated progress | | areas_of_concern | array[string] | Yes | MinItems: 1, MaxItems: 15; item MinLen: 5, MaxLen: 500 | Areas of continued concern or regression | | recommendations | string | Yes | MinLen: 10, MaxLen: 3000 | Clinical recommendations for continued treatment | | continued_treatment_justification | string | Yes | MinLen: 20, MaxLen: 5000 | Medical necessity justification for continued SLP services |

slp_treatment_plan -- SLP Treatment Plan

Class: SyntheticSLPTreatmentPlan
Description: Speech-language therapy treatment plan with diagnosis codes, medical necessity statement, long-term goals, measurable short-term objectives, treatment approaches, and discharge criteria.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | diagnosis_codes | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 3, MaxLen: 50 | ICD-10 diagnosis codes (e.g., F80.1, F80.2, R47.1) | | medical_necessity_statement | string | Yes | MinLen: 20, MaxLen: 5000 | Clinical justification for SLP services | | long_term_goals | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 10, MaxLen: 500 | Long-term treatment goals | | short_term_objectives | array[ShortTermObjective] | Yes | MinItems: 1, MaxItems: 30 | Measurable short-term objectives linked to long-term goals | | treatment_frequency | string | Yes | MinLen: 5, MaxLen: 100 | Frequency and duration of sessions (e.g., 2x/week x 30 min) | | treatment_duration | string | Yes | MinLen: 3, MaxLen: 100 | Total anticipated treatment duration (e.g., 6 months) | | treatment_approaches | array[string] | Yes | MinItems: 1, MaxItems: 15; item MinLen: 3, MaxLen: 200 | Evidence-based treatment approaches (e.g., PROMPT, Hanen, PECS, LAMP, Cycles Approach) | | discharge_criteria | string | Yes | MinLen: 10, MaxLen: 1000 | Criteria for discharge from SLP services | | caregiver_involvement | string | Yes | MinLen: 10, MaxLen: 2000 | Expected caregiver participation and home programming |

Occupational Therapy Documents (3)

ot_evaluation -- OT Evaluation

Class: SyntheticOTEvaluation
Description: Comprehensive occupational therapy evaluation. Documents occupational profile, fine/gross motor skills, visual-motor integration, sensory processing, self-care, standardized assessment results, and treatment recommendations.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | cpt_codes_used | array[string] | Yes | MinItems: 1, MaxItems: 4; Enum per item: 97165, 97166, 97167, 97168 | OT evaluation CPT codes used | | referral_reason | string | Yes | MinLen: 10, MaxLen: 2000 | Reason for referral to occupational therapy services | | occupational_profile | string | Yes | MinLen: 20, MaxLen: 5000 | Client's occupational history, daily routines, interests, and functional concerns | | fine_motor_skills | string | Yes | MinLen: 10, MaxLen: 3000 | Fine motor assessment findings (grasp, manipulation, dexterity) | | gross_motor_skills | string | Yes | MinLen: 10, MaxLen: 3000 | Gross motor assessment findings (balance, coordination, strength) | | visual_motor_integration | string | Yes | MinLen: 10, MaxLen: 3000 | Visual-motor integration and visual perception findings | | sensory_processing | string | Yes | MinLen: 10, MaxLen: 3000 | Sensory processing assessment findings across modalities | | self_care_skills | string | Yes | MinLen: 10, MaxLen: 3000 | ADL/IADL assessment (feeding, dressing, grooming, toileting) | | standardized_assessments | array[string] | Yes | MinItems: 1, MaxItems: 20; item MinLen: 3, MaxLen: 200 | Standardized assessments administered (e.g., BOT-2, Beery VMI, Sensory Profile, PDMS-2) | | assessment_results | string | Yes | MinLen: 20, MaxLen: 5000 | Summary of standardized assessment scores and interpretation | | clinical_impressions | string | Yes | MinLen: 20, MaxLen: 3000 | Clinician's overall impressions and diagnostic formulation | | diagnoses | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 3, MaxLen: 200 | OT-relevant diagnoses (e.g., "F82 Developmental coordination disorder") | | recommendations | array[string] | Yes | MinItems: 1, MaxItems: 15; item MinLen: 5, MaxLen: 500 | Treatment recommendations and referrals | | treatment_frequency | string | Yes | MinLen: 5, MaxLen: 100 | Recommended treatment frequency (e.g., 2x/week x 45 min) |

ot_session_note -- OT Session Note

Class: SyntheticOTSessionNote
Description: Occupational therapy session note documenting treatment area, therapeutic activities, client performance with quantitative data, assistance level, and progress toward goals.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | cpt_code | string | No | Default: 97530 | OT treatment CPT code | | session_duration_minutes | integer | Yes | Min: 15, Max: 60 | Session duration in minutes | | treatment_area | string | Yes | Enum: fine_motor, gross_motor, sensory, self_care, visual_motor | Primary treatment area addressed in session | | activities_used | array[string] | Yes | MinItems: 1, MaxItems: 15; item MinLen: 3, MaxLen: 500 | Therapeutic activities and materials used | | client_performance | string | Yes | MinLen: 10, MaxLen: 3000 | Client performance with quantitative data (e.g., completed 8/10 pegs in 45 seconds) | | assistance_level | string | Yes | MinLen: 5, MaxLen: 300 | Level of assistance required (e.g., minimal assist, moderate assist, maximal assist, independent) | | modifications_made | string or null | No | Default: null; MinLen: 5, MaxLen: 1000 | Any modifications to activities or environment during session | | progress_toward_goals | string | Yes | MinLen: 10, MaxLen: 3000 | Progress toward established treatment goals | | plan | string | Yes | MinLen: 10, MaxLen: 3000 | Plan for next session including targets and strategies |

ot_treatment_plan -- OT Treatment Plan

Class: SyntheticOTTreatmentPlan
Description: Occupational therapy treatment plan with diagnosis codes, medical necessity, functional limitations, long-term goals, measurable short-term objectives, treatment modalities, and discharge criteria.

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | diagnosis_codes | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 3, MaxLen: 50 | ICD-10 diagnosis codes (e.g., F82, F84.0, R27.8) | | medical_necessity_statement | string | Yes | MinLen: 20, MaxLen: 5000 | Clinical justification for occupational therapy services | | functional_limitations | array[string] | Yes | MinItems: 1, MaxItems: 15; item MinLen: 5, MaxLen: 500 | Specific functional limitations impacting occupational performance | | long_term_goals | array[string] | Yes | MinItems: 1, MaxItems: 10; item MinLen: 10, MaxLen: 500 | Long-term treatment goals | | short_term_objectives | array[ShortTermObjective] | Yes | MinItems: 1, MaxItems: 30 | Measurable short-term objectives linked to long-term goals | | treatment_frequency | string | Yes | MinLen: 5, MaxLen: 100 | Frequency and duration of sessions (e.g., 2x/week x 45 min) | | treatment_duration | string | Yes | MinLen: 3, MaxLen: 100 | Total anticipated treatment duration (e.g., 6 months) | | treatment_modalities | array[string] | Yes | MinItems: 1, MaxItems: 15; item MinLen: 3, MaxLen: 200 | Evidence-based treatment modalities (e.g., Sensory Integration, Handwriting Without Tears, Therapeutic Listening, DIR/Floortime) | | discharge_criteria | string | Yes | MinLen: 10, MaxLen: 1000 | Criteria for discharge from OT services | | home_program | string | Yes | MinLen: 10, MaxLen: 2000 | Home program activities and caregiver training plan |

Appendix A: Sub-Models

These are nested object types referenced by the document types above.

BehaviorObservation

Used in: soap_note

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | behavior_name | string | Yes | MinLen: 3, MaxLen: 500 | E.g., "Self-injurious behavior (head hitting)" | | function | BehaviorFunction | Yes | -- | Hypothesized function of behavior | | frequency | integer | Yes | Min: 0, Max: 500 | Count per session | | duration_minutes | number or null | No | Default: null; Min: 0.0, Max: 480.0 | Duration in minutes (if applicable) | | intensity | Severity | Yes | -- | Behavior intensity level | | antecedent | string | Yes | MinLen: 3, MaxLen: 500 | What happened before the behavior | | consequence | string | Yes | MinLen: 3, MaxLen: 500 | What happened after the behavior | | intervention_used | string | Yes | MinLen: 3, MaxLen: 500 | Intervention applied |

ABCEntry

Used in: abc_data

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | timestamp_offset_minutes | integer | Yes | Min: 0, Max: 480 | Minutes from session start | | antecedent | string | Yes | MinLen: 5, MaxLen: 500 | What happened before the behavior | | behavior | string | Yes | MinLen: 5, MaxLen: 500 | Description of the behavior | | consequence | string | Yes | MinLen: 5, MaxLen: 500 | What happened after the behavior | | function_hypothesis | BehaviorFunction | Yes | -- | Hypothesized function | | behavior_category | string | Yes | MinLen: 2, MaxLen: 100 | Category: aggression, elopement, SIB, noncompliance, etc. | | duration_seconds | integer or null | No | Default: null; Min: 0, Max: 7200 | Duration in seconds (if applicable) | | intensity | Severity | Yes | -- | Behavior intensity level |

GoalProgress

Used in: soap_note, slp_progress_report

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | goal_description | string | Yes | MinLen: 5, MaxLen: 500 | E.g., "Client will request items using 2-word phrases" | | domain | string | Yes | MinLen: 2, MaxLen: 100 | E.g., "Manding", "Social Skills", "Daily Living" | | baseline_percentage | number | Yes | Min: 0.0, Max: 100.0 | Baseline performance percentage | | current_percentage | number | Yes | Min: 0.0, Max: 100.0 | Current performance percentage | | target_percentage | number | Yes | Min: 0.0, Max: 100.0 | Target performance percentage | | measurement_method | string | Yes | MinLen: 5, MaxLen: 300 | How progress is measured | | trend | string | Yes | Enum: improving, stable, declining, variable | Performance trend |

TreatmentGoal

Used in: treatment_goals

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | goal_number | integer | Yes | Min: 1, Max: 50 | Sequential goal number | | domain | string | Yes | MinLen: 2, MaxLen: 100 | Communication, Social, Adaptive, Behavior Reduction | | description | string | Yes | MinLen: 10, MaxLen: 1000 | SMART goal format | | baseline | string | Yes | MinLen: 5, MaxLen: 500 | Current baseline performance | | target | string | Yes | MinLen: 5, MaxLen: 500 | Target performance | | measurement | string | Yes | MinLen: 5, MaxLen: 500 | Measurement method | | target_percentage | number | Yes | Min: 0.0, Max: 100.0 | Target percentage | | timeline_months | integer | Yes | Min: 1, Max: 24 | Expected timeline in months | | cpt_code | CptCode | Yes | -- | Associated CPT code | | insurer_specific_language | string or null | No | Default: null; MaxLen: 1000 | Insurer-specific goal language |

GoalSummaryForInsurer

Used in: insurance_auth

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | goal_number | integer | Yes | Min: 1, Max: 50 | Sequential goal number | | description | string | Yes | MinLen: 5, MaxLen: 500 | Goal description | | baseline_percentage | number | Yes | Min: 0.0, Max: 100.0 | Baseline performance percentage | | current_percentage | number | Yes | Min: 0.0, Max: 100.0 | Current performance percentage | | target_percentage | number | Yes | Min: 0.0, Max: 100.0 | Target performance percentage | | status | string | Yes | Enum: met, progressing, plateau, regression | Goal status |

ServiceSummary

Used in: insurance_auth

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | period_start | string | Yes | Len: 10, Pattern: ^\d{4}-\d{2}-\d{2}$ | Service period start date | | period_end | string | Yes | Len: 10, Pattern: ^\d{4}-\d{2}-\d{2}$ | Service period end date | | hours_authorized | number | Yes | Min: 0.0, Max: 2000.0 | Total hours authorized | | hours_delivered | number | Yes | Min: 0.0, Max: 2000.0 | Total hours delivered | | sessions_delivered | integer | Yes | Min: 0, Max: 5000 | Total sessions delivered | | cpt_codes_used | array[CptCode] | Yes | MinItems: 1, MaxItems: 10 | CPT codes used during period |

ShortTermObjective

Used in: slp_treatment_plan, ot_treatment_plan

| Field | Type | Required | Constraints | Description | |-------|------|----------|-------------|-------------| | objective | string | Yes | MinLen: 10, MaxLen: 500 | Specific, measurable short-term objective | | baseline | string | Yes | MinLen: 3, MaxLen: 300 | Current baseline performance | | target | string | Yes | MinLen: 3, MaxLen: 300 | Target performance criterion | | measurement_method | string | Yes | MinLen: 5, MaxLen: 300 | How progress will be measured (e.g., percentage accuracy, frequency count) | | timeline | string | Yes | MinLen: 3, MaxLen: 100 | Expected timeline to achieve objective (e.g., 3 months) |

Appendix B: Document Type Quick Reference

| # | case_type | Class | Discipline | Fields (excl. base) | |---|-------------|-------|------------|---------------------| | 1 | soap_note | SyntheticSOAPNote | ABA | 10 | | 2 | abc_data | SyntheticABCRecord | ABA | 6 | | 3 | treatment_goals | SyntheticTreatmentGoals | ABA | 4 | | 4 | insurance_auth | SyntheticInsuranceAuth | ABA | 8 | | 5 | crisis_plan | SyntheticCrisisPlan | ABA | 10 | | 6 | supervision_note | SyntheticSupervisionNote | ABA | 12 | | 7 | discharge_summary | SyntheticDischargeSummary | ABA | 10 | | 8 | progress_report | SyntheticProgressReport | ABA | 13 | | 9 | session_data | SyntheticSessionData | ABA | 15 | | 10 | assessment_section | SyntheticAssessmentSection | ABA | 10 | | 11 | psychotherapy_note | SyntheticPsychotherapyNote | Psychotherapy | 12 | | 12 | psychiatric_eval | SyntheticPsychiatricEval | Psychotherapy | 13 | | 13 | mental_status_exam | SyntheticMentalStatusExam | Psychotherapy | 12 | | 14 | safety_plan | SyntheticSafetyPlan | Psychotherapy | 9 | | 15 | group_therapy_note | SyntheticGroupTherapyNote | Psychotherapy | 11 | | 16 | family_therapy_note | SyntheticFamilyTherapyNote | Psychotherapy | 10 | | 17 | psychological_testing | SyntheticPsychologicalTesting | Psychotherapy | 10 | | 18 | substance_abuse_assessment | SyntheticSubstanceAbuseAssessment | Psychotherapy | 12 | | 19 | slp_evaluation | SyntheticSLPEvaluation | SLP | 16 | | 20 | slp_session_note | SyntheticSLPSessionNote | SLP | 11 | | 21 | slp_progress_report | SyntheticSLPProgressReport | SLP | 10 | | 22 | slp_treatment_plan | SyntheticSLPTreatmentPlan | SLP | 9 | | 23 | ot_evaluation | SyntheticOTEvaluation | OT | 14 | | 24 | ot_session_note | SyntheticOTSessionNote | OT | 9 | | 25 | ot_treatment_plan | SyntheticOTTreatmentPlan | OT | 10 |