Sign Up
Login
Try for Free
Login
The BDI-3 (Battelle Developmental Inventory, Third Edition) is a norm-referenced battery for birth through 7 years 11 months, scoring five IDEA-aligned domains through structured tasks, observation, and interview. Early-intervention and preschool teams use it for eligibility and federal outcome reporting. It is unrelated to the Beck Depression Inventory (BDI-II). This page covers how to write up BDI-3 results, with a fictional sample.
Early-intervention and preschool evaluation teams (special educators, SLPs, OTs, PTs, psychologists); the publisher lists a low purchase-restriction level, with state programs adding their own training rules
Part C and Section 619 eligibility teams, IFSP and IEP teams, state data systems and federal outcome reporting, referring physicians and NICU follow-up, families
400 to 800 words for the results section · Screening Test 10 to 30 minutes; the full battery commonly spans sessions (roughly 60 to 90 minutes of testing time)
Norm-referenced developmental battery (five IDEA-aligned domains, 13 subdomains; structured tasks, observation, and informant interview)
Part C eligibility and recurring assessment, preschool transition at age three, federal child-outcome reporting at entry and exit, re-evaluations documenting progress
Third edition published by Riverside Insights (2020; the BDI-2 was sunset in 2023); named in many state systems; described here for write-up purposes, no test content reproduced
The Battelle Developmental Inventory, Third Edition (BDI-3; Newborg; Riverside Insights, released 2020) is one of the two dominant early-childhood eligibility batteries in US practice. It spans birth through 7 years 11 months across five domains that mirror IDEA's developmental areas, Adaptive, Social-Emotional, Communication, Motor, and Cognitive, divided into 13 subdomains (several of which, including Peer Interaction and Perceptual Motor, begin at age 2). Items can be administered through structured tasks, observation, or caregiver and teacher interview, scored on a graded full, partial, or no-credit basis with three-consecutive-response basal and ceiling rules. Three separately sold components matter to reports: the Developmental Complete (the full battery), the BDI-3 Screening Test (about 100 items, 10 to 30 minutes, a flagging tool), and the Battelle Early Academic Survey, a literacy and mathematics add-on for ages 3:6 to 7:11. Scoring runs through licensed paper forms or the Riverside Score platform, which reports Developmental Quotients (mean 100, SD 15) with confidence intervals, subdomain scaled scores (mean 10, SD 3), percentiles, growth-oriented Change Sensitive Scores, and eligibility outputs including months, percentage, and standard-deviation delay.
Two identity facts do heavy lifting on this page. First, the acronym: the BDI-3 is a developmental assessment for young children and has nothing to do with the Beck Depression Inventory (BDI-II), Pearson's depression measure for ages 13 and up; records systems collide on "BDI," so the full name appears at first mention and bare "BDI" never appears in tables, problem lists, or export fields. Second, the edition: the BDI-2 was formally sunset in 2023 (final kits mid-2023, final record forms at year end), the third edition renamed the old Personal-Social domain to Social-Emotional (spotting "Personal-Social" in purported BDI-3 material is the reliable edition-drift detector), and the publisher itself warns that BDI-2 and BDI-3 scores are not directly comparable, so cross-edition change claims are measurement discontinuities, not progress. The DAYC-2 page covers the other major eligibility battery, and the Bayley-4 page the structured infant-toddler alternative.
State early-intervention and preschool systems are the BDI-3's home: Massachusetts moved its statewide early-intervention assessment to the BDI-3 in January 2025 for eligibility and outcomes, Tennessee uses it for initial eligibility, recurring assessment, and federal reporting through its state data system, New Jersey mandates the full Developmental Complete by two evaluators (results valid four months, telehealth administration prohibited), Texas transitioned from the BDI-2 in 2023 and now lets teams choose the BDI-3 or the DAYC-2, and South Dakota uses BDI-3 entry and exit data for its preschool outcomes indicator. Those examples show the same instrument doing different jobs, initial eligibility, program planning, annual reassessment, transition, and Part C Indicator 3 or Part B Indicator 7 outcome reporting, and a defensible report names which job this administration performed. The federal frame is constant: evaluation within 45 days of referral, no single measure as the sole eligibility criterion in either Part C or Part B, informed clinical opinion able to establish but never negate eligibility, and transition conferences at least 90 days before the third birthday. Clinical settings bill comprehensive developmental testing under the 96112 family where payer rules permit. Adaptive behavior at depth belongs to the Vineland-3 and ABAS-3 pages; the broader process frame lives on the developmental assessment page.
No authority prescribes a BDI-3 report format, but the instrument's flexibility and its legal contexts dictate the load-bearing elements: the full name with the Beck disambiguation, the exact component and edition, sources per domain, uncertainty around every quotient, adaptive integration without double-counting, an eligibility statement in the state rule's own currency, and a clean separation between eligibility and outcome reporting. Each section below carries the pitfall that most often undermines it.
Identification, in full, with the disambiguation. First mention: Battelle Developmental Inventory, Third Edition, naming the component administered (Developmental Complete, Screening Test, or with the Early Academic Survey added) and the platform (paper or Riverside Score). Add one sentence that this developmental assessment is unrelated to the Beck Depression Inventory (BDI-II), then use BDI-3. Record chronological age, any corrected age with its state authority, testing dates, examiners and disciplines, setting, and language. Pitfall: Bare "BDI" in a table header, EHR field, or export. Two unrelated instruments share the acronym, records systems match on strings, and the Beck collision is a real chart-safety hazard, not pedantry.
Edition and component boundaries. Confirm the write-up describes the third edition: Social-Emotional (not the BDI-2's Personal-Social), 2020 norms, current scoring criteria. Say explicitly whether the full battery or the Screening Test was given: the screener yields a flagging score, not a DQ profile, and cannot be dressed as comprehensive results. Where prior testing used the BDI-2, treat the edition change as a measurement discontinuity rather than computing change. Pitfall: Edition drift: Personal-Social terminology, BDI-2 crosswalks, or "gained eight points since 2022" across editions the publisher itself calls non-comparable.
Administration and sources, per domain. Describe how information was obtained, structured administration, observation, caregiver or teacher interview, and how it varied by domain and subdomain; note multi-day or multi-examiner administration with every examiner and date (the platform records these per subdomain), accommodations, and which subdomains were age-inapplicable (several begin at age 2). Pitfall: A three-day, three-discipline arena assessment presented as one uninterrupted session, or interview-derived credit reading as elicited performance. The source labels are the evidence.
Validity statement with content. Address engagement and regulation, hearing, vision, motor, language, and cultural factors, opportunity to perform the sampled skills, whether accommodations preserved standardization, and disagreements between informant report and observation, then conclude: valid, cautiously interpretable, or descriptive only. Pitfall: "Results are considered valid" as boilerplate. The sentence has to earn itself with what was actually observed.
Domain results with intervals, scatter before the total. Report each domain Developmental Quotient with its confidence interval and percentile, then the subdomain scaled scores wherever they explain meaningful scatter (receptive versus expressive; gross versus fine motor; structured cognition versus functional application). Report the Total DQ, but when domains diverge, say plainly that the global score is not a sufficient summary and center the domain findings. Keep age equivalents secondary. Pitfall: A Total DQ doing eligibility work over an uneven profile, or bare quotients at a threshold: a DQ of 79 with an interval crossing the criterion is a different sentence from one clearly below it.
Adaptive integration and the eligibility statement. When a Vineland-3 or ABAS-3 was also given, integrate rather than double-count: overlapping constructs, different respondents and methods, one adaptive conclusion. Then write eligibility in three separated statements: the normative interpretation (how many SDs below the mean), the state's quoted criterion in its own currency (an SD rule reads off the DQ; a percent-delay rule uses the state's own age-equivalent formula, and the two are not interchangeable), and the team's multisource determination. Pitfall: "Eligible because the BDI-3 was low." No single measure may decide eligibility, a DQ is a standard score that cannot be subtracted from 100 to yield percent delay, and informed clinical opinion can add but never subtract a qualifying result.
Outcomes, progress, and the family summary. If the administration feeds federal outcome reporting, say which indicator, whether this is entry, interim, or exit, and how the crosswalk and team process were used (domain scores are the smallest crosswalkable unit, and the crosswalk is not a checklist); at re-evaluation, use the Change Sensitive Score to document absolute growth alongside the current DQ for normative standing. Close with a plain-language family summary: strengths, priority needs, examples from routines, and the next step. Pitfall: Outcome reporting conflated with eligibility, "scores went up" read as "no longer eligible" (peers advanced too), or a report that ends at classifications with nothing a family can use.
BDI-3 RESULTS SECTION SKELETON Child: [initials] Evaluation date(s): [ ] Evaluator(s) + discipline(s): [ ] Instrument: Battelle Developmental Inventory, Third Edition (BDI-3), [Developmental Complete / Screening Test / + Early Academic Survey] Platform: [paper / Riverside Score / Mobile Data Solution] (Unrelated to the Beck Depression Inventory, BDI-II.) Chronological age: [ ] Corrected age (if used): [ ] (authority: [state policy]; effect on scoring stated) Referral question: [ ] Program + eligibility rule applied: [state/program; criterion quoted in its own currency] Administration + sources: [structured / observation / caregiver or teacher interview, by domain; examiners and dates per subdomain; accommodations; subdomains not age-applicable noted] Validity statement: [engagement, sensory and motor factors, language, opportunity, informant-observation disagreements; conclusion] Domain results (each with uncertainty): [Domain]: DQ [ ] (mean 100, SD 15), CI [ ], percentile [ ] Subdomain scaled scores (mean 10, SD 3) where scatter matters: [ ] Total DQ: [ ] (CI [ ]); [sufficient summary / not a sufficient summary because ...] Adaptive integration (if Vineland-3 / ABAS-3 given): [convergence or divergence; one adaptive conclusion, not two counts] Eligibility statement (three parts): [normative interpretation (SDs below mean) / quoted state criterion / team's multisource determination; informed clinical opinion role] Outcome reporting (if applicable): [Indicator 3 or 7; entry, interim, exit; crosswalk + team process; same-edition comparison only] Progress at re-evaluation: [Change Sensitive Score growth + current DQ standing; no cross-edition change claims] Family summary (plain language): [strengths, needs, routine examples, next step] Evaluator signature / credentials: Date:
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank results-section skeleton, ready to adapt. Neither reproduces test items, record forms, norms, or conversion tables.
Scenario: an 18-month-old referred for limited words and social reciprocity, evaluated by a two-evaluator Part C team, qualifying on communication and social-emotional findings under a named rule. All details are fictional.
Patient: J.M., 18 months · Setting: Part C early intervention eligibility evaluation, two-evaluator team · Clinician: R. Casteel, MEd (coordinating evaluator) · Note date: 08/24/2026
Identification: Battelle Developmental Inventory, Third Edition (BDI-3), Developmental Complete, administered on paper record forms with scoring through the licensed platform, 08/24/2026, by this evaluator and a speech-language pathologist as a two-evaluator team. This developmental assessment is unrelated to the Beck Depression Inventory (BDI-II). J.M. was 18 months 9 days, born at term; chronological age anchored all scoring. Referral: limited spoken words and reduced social reciprocity noted by the family and pediatrician. Eligibility rule applied: our program defines developmental delay as at least 1.5 standard deviations below the mean in two or more developmental areas.
Administration and validity: Information came from structured activities, observation during floor play, and caregiver interview, varying by subdomain as the instrument permits; sources are attributed throughout, and interview-derived credit is identified as reported. Peer Interaction, Personal Responsibility, Perceptual Motor, and Reasoning and Academic Skills were not administered because they begin at age 2. J.M. regulated well with brief breaks, hearing screening earlier this month was passed, and the session was judged representative by his mother: results considered valid.
Results: Motor DQ 94 (90 percent CI 88 to 100, 35th percentile) and Adaptive DQ 88 (CI 82 to 95, 21st percentile) fell within broad average limits. Cognitive DQ 84 (CI 78 to 91, 14th percentile) was low average, with the narrative noting that several cognitive items carry language demands, so this figure may partly reflect the communication picture. Communication DQ 68 (CI 63 to 75, 2nd percentile) was the profile's clearest weakness, receptive scaled score 6 sitting above expressive 4, both below expectations. Social-Emotional DQ 76 (CI 70 to 83, 5th percentile) was also below expectations, with Adult Interaction relatively spared and Self-Concept and Social Role items depressed. The Total DQ is reported in the score table but is not a sufficient summary of this uneven profile; the domain findings carry the interpretation.
Eligibility analysis: Normatively, Communication fell more than 2 standard deviations below the mean and Social-Emotional about 1.6 below, each with its confidence interval below the criterion line. Under the program's quoted rule (1.5 SD in two or more areas), both areas meet the threshold in the rule's own currency; no percent-delay conversion is offered because the criterion is SD-based and the two metrics are not interchangeable. Caregiver report, direct observation, the pediatrician's referral concerns, and the speech-language pathologist's findings converge. Per Part C requirements, no single measure decides eligibility: the multidisciplinary team, applying informed clinical opinion, determined that J.M. meets the program's definition of developmental delay in communication and social-emotional development.
Family summary and next steps: In plain terms, reviewed with J.M.'s parents: he moves well, feeds himself, solves little problems in play, and is warmly attached to familiar adults. Talking, and some of the back-and-forth of play, are what is hard right now, and he met the program's definition of delay in those two areas. What his parents described at home matched what the team saw. Next: the IFSP meeting is scheduled within the program's timeline to plan supports built into daily routines, with outcome-reporting entry data recorded from this same administration and any future re-evaluation using this same edition so growth can be measured honestly.
This sample is fictional and for educational purposes. It does not describe a real child or record; the scores, dates, and details are invented to show write-up structure and are not clinical guidance. Scores are invented for illustration and correspond to no real child or record, and no norm-table values are reproduced.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsUnited States: the report answers to two laws and fifty-plus rulebooks. IDEA Part C requires evaluation, assessment, and the initial IFSP meeting within 45 days of referral, prohibits any single procedure as the sole eligibility criterion, and requires informed clinical opinion, which can establish eligibility the instruments miss but can never negate a qualifying result; Part B carries its own initial-evaluation timeline (commonly 60 days from consent), its own no-single-measure rule, and the transition machinery that puts a conference at least 90 days before the third birthday and an IEP in effect by it for eligible children (LAW). State definitions supply the arithmetic: a 2026 federal technical-assistance compilation counts 19 jurisdictions with a 2-SD-in-one-area criterion, 19 with 1.5 SD in two or more areas, 18 with a 25 percent delay, and overlapping others, so the report quotes the rule it applies. State Battelle practice is equally specific: Massachusetts moved statewide to the BDI-3 in January 2025 for eligibility and outcomes and warns against treating edition change as child change; Tennessee runs eligibility and recurring outcome assessment through its state data system without billing families; New Jersey mandates the Developmental Complete by two evaluators with four-month validity and no telehealth administration; Texas permits BDI-3 or DAYC-2; South Dakota's verified use is Indicator 7 outcome reporting (PROGRAM POLICY). Clinical billing under 96112 and 96113 follows payer rules and never doubles school or Part C work (PAYER POLICY).
Canada and Australia buy the same kit into different systems. The BDI-3 launched with Canadian availability and is distributed through Nelson, but education and early-childhood identification are provincial matters with no national eligibility framework and no province-wide rule naming the Battelle, so a Canadian report identifies the actual program and criteria and weighs the fit of US-based norms (the English standardization sample is US-national; the separate Spanish sample is US bilingual) (PROGRAM POLICY, provincial). In Australia the BDI-3 is distributed through PAA and can contribute developmental evidence to the NDIS early childhood approach, which supports children under six on developmental delay or concern without a diagnosis and children under nine with disability, and whose evidence guidance centers on functional capacity, everyday participation, and support needs rather than any instrument cutoff; NDIS processes remain in active change through 2026, and the separate national Preschool Outcomes Measure pilot is a formative educator tool, not a standardized diagnostic to be conflated with Battelle outcome reporting (LAW and PROGRAM POLICY). Across all three countries the outcome-versus-eligibility distinction travels: federal US outcome reporting uses the ECTA crosswalk (updated February 2026) with domain scores as the smallest crosswalkable unit and an explicit warning that crosswalks are not checklists, and no jurisdiction anywhere reads a screener as a comprehensive evaluation.
Editions, rights, and evidence honesty are where Battelle write-ups most often overreach. The third edition's English norms come from about 2,500 children in 20 age groups, gathered by 283 examiners in 44 states and weighted to 2020 census projections, with a separate roughly 1,000-child Spanish bilingual sample; publisher-reported reliability is strong (internal consistency about .92 to .97, test-retest about .79 to .87) but the publicly displayed interrater table covers only two domains (.82 and .97), so blanket interrater claims outrun the source. Independent peer-reviewed BDI-3 validation is essentially absent as of August 2026: the Buros review sits in the recently published Twenty-Second Mental Measurements Yearbook behind a paywall, screener accuracy ranges (sensitivity 0.80 to 0.94, specificity 0.76 to 0.84 in a state summary) derive from publisher documentation, no public infant floor-effect statistics exist, and the standing scholarly critique (the authentic-assessment literature) argues norm-referenced batteries under-represent young children's everyday functioning, which is exactly why observation, routines, and family evidence share the record. Rights are conventional: record forms are licensed consumables, no free public scorer exists (scoring runs through the subscription platform), EHR and state-system integration is a results-export matter rather than permission to recreate test content, and prematurity correction has no universal Battelle rule, so the state policy governs and the Bayley's correction convention must not be imported. Per the publisher's current legal notice, Battelle is a registered trademark of Battelle Memorial Institute, BDI-3 of LINC Associates, Inc., and Riverside Insights of Riverside Assessments, LLC. BastionGPT is not affiliated with, or endorsed by, any of these trademark owners or the publisher. This page reproduces no test items, stimuli, norms, or scoring materials.
The numbers behind these errors are specific. The BDI-3's English norms rest on about 2,500 children across 44 states; the publisher's public interrater table covers only two domains (.82 and .97); screener accuracy ranges (sensitivity 0.80 to 0.94) are publisher-derived, per a state evidence summary; and a 2026 analysis found thousands of combinations where age-equivalent percent delay and standard scores disagree on eligibility. The BastionGPT Clinical Advisory Board sees the same errors most often in BDI-3 documentation reviews:
BastionGPT is specifically trained, tuned, and clinically tested on psychological and psychoeducational evaluation reports.
See how clinicians use it day to day on the AI therapy notes page.
Many BastionGPT users report saving more than 90 minutes per day on documentation.
HIPAA-compliant with a signed BAA on every plan. Your data is never used to train models. BastionGPT drafts, you review and sign.
Developmental Quotients (mean 100, SD 15) for each of the five domains and a Total DQ, each with a confidence interval (the publisher's sample reporting shows 95 percent intervals on domains and 90 percent on the total); subdomain scaled scores (mean 10, SD 3) beneath them; percentile ranks and related metrics; age equivalents, which stay secondary; a growth-purposed Change Sensitive Score centered so 500 represents a typical 36-month-old's level, built for comparing two administrations; and eligibility outputs through the scoring platform including months delay, percentage delay, and standard-deviation delay. Two structural rules govern reporting: a valid domain DQ requires all age-applicable subdomains in that domain, and a valid Total DQ requires all five domains, with the platform withholding scores (and issuing age-range warnings) when subdomains fall outside the child's age band, since several begin at age 2.
No, and the collision is worth engineering against. The BDI-3 is the Battelle Developmental Inventory, Third Edition (Riverside Insights, 2020), a developmental battery for children from birth through 7 years 11 months. The BDI-II is the Beck Depression Inventory, Second Edition (Pearson), a self-report depression measure for ages 13 and older. They share nothing but letters, yet EHR fields labeled "BDI," export tables that strip hyphens, search snippets, and clinical libraries holding both instruments create genuine chart-safety risk, and Pearson's own catalog styles the Beck as both "BDI-II" and "BDI-2," so punctuation alone cannot disambiguate. The working conventions: spell out the full name at first mention in every report, write "Battelle (BDI-3)" and "Beck (BDI-II)" wherever a field or table forces brevity, and never let bare "BDI" into a problem list.
The third edition (2020) brought renormed scores weighted to 2020 census projections, repositioned and rescored content, the Riverside Score platform with mobile administration, a separate Spanish bilingual standardization sample, the new Early Academic Survey, and a renamed domain: the BDI-2's Personal-Social became the BDI-3's Social-Emotional, which makes stray "Personal-Social" wording the reliable detector of second-edition material masquerading as current. The BDI-2 was formally sunset in 2023 (final kits mid-year, final record forms at year end), and any post-transition administration needs a named local authority. On comparison, the publisher's own answer is no: BDI-2 and BDI-3 scores are not directly interchangeable, so longitudinal write-ups treat the edition change as a measurement discontinuity, re-baseline on the BDI-3, and use same-edition Change Sensitive Scores for genuine progress claims, exactly as state transition guidance (Massachusetts, notably) instructs.
The state's rule decides, and the DQ is not a ratio you can turn into percent delay. Standard scores map onto SD-based criteria directly (a DQ of 70 sits 2 SD below the mean; 77.5 at 1.5 SD), and the state landscape genuinely varies: 19 jurisdictions carry a 2-SD-in-one-area criterion, 19 carry 1.5 SD in two or more areas, 18 carry a 25 percent delay, with most offering multiple routes. The trap is the label: the BDI-3 Developmental Quotient is a norm-referenced standard score, not developmental age divided by chronological age, so subtracting it from 100 yields nothing, and where a state requires percent delay the calculation runs through age equivalents under that state's exact formula, a psychometrically weaker metric that can disagree with the standard score for the same child. Then the law finishes the sentence: no single measure may determine eligibility, informed clinical opinion can establish what scores miss but never negate what they find, and the multidisciplinary team owns the decision.
As a general rule, no: it flags, the full battery evaluates. The Screening Test draws about 100 items across the five domains and thirteen subdomains, runs 10 to 30 minutes, and yields a screening total whose job is to identify children needing complete assessment; it does not produce the domain DQ profile that eligibility analysis and program planning require, and federal law's variety-of-tools requirement bars any single measure, screener included, from settling eligibility. State rules can be stricter still: New Jersey mandates the BDI-3 Developmental Complete administered by two evaluators, treats results as valid for four months, and prohibits telehealth administration. The defensible screening write-up therefore names the component ("BDI-3 Screening Test"), reports the broad areas of concern with sources and validity notes, and documents the follow-up evaluation plan, never borrowing full-battery language like "comprehensive developmental profile."
Yes, by design, provided the report shows it. Items may be obtained through structured administration, observation, or caregiver and teacher interview depending on the item; domains can be divided among disciplines in an arena model; and the scoring platform records a separate examiner and date per subdomain, with the publisher's own sample report documenting an assessment across three days. The write-up obligations follow directly: name every examiner, discipline, and date; label the method behind each domain's findings rather than presenting reported skills as elicited ones; follow the start-point, basal (three consecutive full-credit), and ceiling (three consecutive no-credit) rules consistently; note subdomains outside the child's age band (several begin at age 2); and keep the whole process inside the governing timeline, 45 days from referral to the initial IFSP in Part C. Platform flexibility is not a waiver of standardization, and a three-session battery presented as one sitting misstates the evidence.
As a data source with its own crosswalk, kept separate from eligibility. Federal early-childhood outcome reporting (Part C Indicator 3; Part B preschool Indicator 7) rates three functional outcomes, and the ECTA Center's BDI-3 crosswalk (updated February 2026) maps domains and subdomains to them, with two explicit warnings: domain scores are the smallest unit that can be directly assigned, and the crosswalk is not a checklist, so family input and observation across routines remain required, whether a state computes ratings from entered data or runs the team-based summary process. The write-up states which indicator, whether the administration is entry, interim, or exit, and which edition was used at each point. For progress, the purpose-built metric is the Change Sensitive Score, which documents absolute skill growth between administrations, paired with the current DQ for normative standing: scores can rise while the child remains eligible because age peers advanced too, and only same-edition comparisons count.
Yes. Give it the facts (component and edition, ages and any state-authorized correction, domains with each one's sources and examiners, DQs with intervals and subdomain scatter, the quoted state rule, adaptive measures administered, and the outcome-reporting role) and it drafts the results section: disambiguated first mention, sources labeled, scatter handled before the total, the three-part eligibility statement, and a plain-language family summary, ready for your review. It can also cross-check a finished report for a bare "BDI," edition-drift wording, screener results in full-battery clothing, a DQ-to-percent-delay conversion, or a double-counted adaptive finding, and it can draft re-evaluation and transition variants. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
The instrument facts and compliance claims on this page trace to these sources, last verified August 2026:
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.