Updated - Session Notes

RBT PREP: Documentation and Reporting

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RBT TASK LIST E:

E-1 Effectively communicate with a supervisor in an ongoing manner.

E-4 Generate objective session notes for service verification by describing what occurred during the sessions, in accordance with applicable legal, regulatory, and workplace requirements.

E-2 Actively seek clinical direction from supervisor in a timely manner

E-5 Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements.

E-3 Report other variables that might affect the client in a timely manner.

Why do session notes matter?

Communication and Collaboration: Session notes facilitate communication among professionals involved in the client's care, including behavior analysts, supervisors, caregivers, and other healthcare professionals. Clear and concise notes ensure that everyone involved is informed about the client's progress, enabling better collaboration and coordinated care.

Documentation of Client Progress: Session notes serve as a detailed record of what occurred during therapy sessions. They document the client's progress, behaviors observed, interventions used, and outcomes achieved. This documentation is essential for tracking changes in behavior over time and assessing the effectiveness of the applied interventions.

Why do session notes matter?

Individualized Treatment Planning: Session notes help in tailoring individualized treatment plans for clients. By documenting specific behaviors, responses to interventions, and any modifications made during sessions, RBTs can adjust and refine treatment strategies to better suit the client's needs.

Legal and Ethical Purposes: Detailed and accurate session notes are essential for legal and ethical reasons. They serve as evidence of the services provided, interventions used, and the rationale behind decision-making in case of audits, legal inquiries, or insurance claims.

RBT TASK LIST E:

E-1 Effectively communicate with a supervisor in an ongoing manner.

E-4 Generate objective session notes for service verification by describing what occurred during the sessions, in accordance with applicable legal, regulatory, and workplace requirements.

E-2 Actively seek clinical direction from supervisor in a timely manner

E-5 Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements.

E-3 Report other variables that might affect the client in a timely manner.

E-1 Effectively communicate with a supervisor in an ongoing manner.

Expressing ideas and professional opinions with healthy assertiveness while also understanding your role in complying with your supervisor’s treatment planning.

Accepting feedback and responding appropriately to feedback and communication from your supervisor.

Engaging in regular communication with your clinical team.

E-1 Effectively communicate with a supervisor in an ongoing manner.

Your client ate hot dogs for lunch

Knowing what situations should result in immediate or more urgent communication with your supervisor and knowing what situations can wait until your supervisor attends session or observation or has a meeting with you to discuss the case or client.​

You have an idea on how you can run an existing goal with your client to increase independent trials

Your client has a sudden or significant change in behavior causing danger to themselves or you.

RBT TASK LIST E:

E-1 Effectively communicate with a supervisor in an ongoing manner.

E-4 Generate objective session notes for service verification by describing what occurred during the sessions, in accordance with applicable legal, regulatory, and workplace requirements.

E-2 Actively seek clinical direction from supervisor in a timely manner

E-5 Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements.

E-3 Report other variables that might affect the client in a timely manner.

E-2 Actively seek clinical direction from supervisor in a timely manner.

As an RBT, it is your duty to proactively seek guidance and direction from your supervisors when necessary. If there's uncertainty about protocols or steps to be taken in various client scenarios, promptly reaching out to a supervisor for clear guidance before the next session is typically required.

sHOULD I TELL THEM.... STOP, YIELD, OR GO?

STOP! YOU DON'T NEED TO NOTIFY YOUR SUPERVISOR

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YIELD YOU CAN WAIT UNTIL AFTER SESSION

GO TELL YOUR SUPERVISOR ASAP

sHOULD I TELL THEM.... STOP, YIELD, OR GO?

sHOULD I TELL THEM.... STOP, YIELD, OR GO?

sHOULD I TELL THEM.... STOP, YIELD, OR GO?

sHOULD I TELL THEM.... STOP, YIELD, OR GO?

RBT TASK LIST E:

E-1 Effectively communicate with a supervisor in an ongoing manner.

E-4 Generate objective session notes for service verification by describing what occurred during the sessions, in accordance with applicable legal, regulatory, and workplace requirements.

E-2 Actively seek clinical direction from supervisor in a timely manner

E-5 Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements.

E-3 Report other variables that might affect the client in a timely manner.

E-3 Report other variables that might affect the client in a timely manner.

While antecedents can act as triggers for behavior, setting events represent larger situational experiences.Examples of setting events: Sickness Sleep deprivation Biological necessities (such as hunger) Alterations in the client's home environment

An RBT should take into account numerous factors related to a client's functioning. In the realm of Applied Behavior Analysis, setting events are occasionally overlooked as influencers of behavior. Setting events encompass broader experiences that can impact a client.

RBT TASK LIST E:

E-1 Effectively communicate with a supervisor in an ongoing manner.

E-4 Generate objective session notes for service verification by describing what occurred during the sessions, in accordance with applicable legal, regulatory, and workplace requirements.

E-2 Actively seek clinical direction from supervisor in a timely manner

E-5 Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements.

E-3 Report other variables that might affect the client in a timely manner.

E-4 Generate objective session notes for service verification by describing what occurred during the sessions, in accordance with applicable legal, regulatory, and workplace requirements.

session note requirements

TIMELY:session notes are completed during the last 15 minutes of session

HONEST:You MUST write an authentic note. (no copy and pasting from previous sessions)

CLEAR: Session notes should be concise, objective and always include a measurement.

ETHICAL: Session notes may only be written on a work-issued device.Never write out your client name. (Refer to them as client)

Now... explain to me as if I were five years old?

SESSION NOTE FORMULA FOR SUCCESS

quick! click the bell to reveal a secret

M- measureable

O- observable

O- objective

Subjective

vs.

Objective

Objective

We want our sessiont notes to be

Client was sad at the start of session.

Client had 4 tantrums during session.

Client eloped during the learning activity.

Subjective

Objective

Objective

Client wanted to play candyland.

Client cried because mom removed the IPad.

Subjective

Subjective

Subjective

vs.

Objective

Objective

We want our sessiont notes to be

Caregiver informed the RBT that the client got 4 hours of sleep

Client told the RBT that they felt sad and began crying

RBT tried really hard to get client to play Uno.

Objective

Subjective

Objective

Client had so much fun playing soccer. They smiled with pure joy.

Client responded after RBT prompted with a gesture.

Subjective

Objective

Examples:

Body Language:

Updates/reports:

Noteworthy:

• Caregiver reported learner had a good day at school.
• Caregiver reported learner got 3 hours of sleep

• Learner began school this month on the 10th.
• Grandma is visiting family for 2 weeks.

• Learner entered session smiling
• Learner stood behind caregivers and did not make eye contact

NON-Examples:

Body Language:

Updates/reports:

Noteworthy:

• Learner entered session happy
• Learner shyly peeked at us from behind caregivers

• Learner felt sad about going back to school
• Caregiver looks anxious

• Learner enjoys eating sushi
• Learner blinked a lot in session

Try it out!

click the power button on the SCREEN TO BEGIN THE ACTIVITY

dont forget about the secret formula

RBT TASK LIST E:

E-1 Effectively communicate with a supervisor in an ongoing manner.

E-4 Generate objective session notes for service verification by describing what occurred during the sessions, in accordance with applicable legal, regulatory, and workplace requirements.

E-2 Actively seek clinical direction from supervisor in a timely manner

E-5 Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements.

E-3 Report other variables that might affect the client in a timely manner.

E-5 ENSURE COMPLIANCE WITH RELEVANT LEGAL, REGULATORY, AND WORKPLACE STANDARDS FOR DATA COLLECTION, STORAGE, TRANSPORTATION, AND DOCUMENTATION.

Client information and data are protected by privacy law:- Only transport documents as directed by your BCBA- Documents must be stored in a secure place- All private information should be kept in a safe or other locked container- Client information must only be viewed on work issued devices

Never share client data with anyone who hasn't been given explicit permission to receive data

The BACB requires that data be kept for a minimum of 7 years unless otherwise specified by state or local law

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YELLOW: YIELD

Slow down! You can wait till after session to let your BCBA know about how you can implement a goal. This information is crucial to communicate to your supervisor but it is not necessarily an urgent matter.

Get ready to dive into the world of session notes! This video will guide you through the art of taking effective session notes and their importance in your practice.

SESSION NOTE SECRET FORMULA

Overall Session Notes: Overall Session Notes:

• Client's body language entering session:
• Client/caregiver reports:
• Noteworthy behaviors or barriers observed in session:

Target 1:

• Antecedent (Activity/SD/Who/etc):
• Behavior (Specific measurement/prompts/redirects/etc):
• Consequence (reinforcement/follow through/etc):

Target 2:

• Antecedent (Activity/SD/Who/etc):
• Behavior (Specific measurement/prompts/redirects/etc):
• Consequence (reinforcement/follow through/etc):

Target 3:

• Antecedent (Activity/SD/Who/etc):
• Behavior (Specific measurement/prompts/redirects/etc):
• Consequence (reinforcement/follow through/etc):

Follow up:

• What goal client did well with:

• What goal client struggled with:

• Plan for next session to improve client skills:

Documentation and Reporting

In this module, we will be reviewing Task List E—an integral component of the RBT certification process. Join us for an insightful exploration of the essential skills and competencies required for Registered Behavior Technicians. Get ready to deepen your understanding and excel in your RBT journey!

GREEN: GO

GO INFORM YOUR SUPERVISOR!Any immediate safety risks to the client, yourself, or others should prompt immediate contact with your BCBA. This includes instances of physical aggression, self-injurious behavior, or emergencies where immediate intervention is required.

RED: STOP

STOP!! Please ensure that any messages or communications sent are directly related to the treatment or the progress of our clients. Focusing our discussions on matters that impact our clients' well-being and progress helps us maintain a more efficient and focused approach in our communication channels. Thank you for your understanding and commitment to our clients' care.

While watching this video take data. ****NEED TO WORK ON THIS SECTION