This page of our free RBT Exam Study Guide covers documentation and reporting. This is based on Section E of the RBT Task List, which includes the following tasks related to documentation and reporting:
- Effectively communicate with a supervisor in an ongoing manner
- Actively seek clinical direction from a supervisor in a timely manner
- Report other variables that might affect the client in a timely manner
- Generate objective session notes for service verification by describing what occurred during the sessions in accordance with applicable legal, regulatory, and workplace requirements
- Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements
Significance of documentation and reporting: ABA is data-driven, which means documentation is essential for the ongoing progression of therapy. Documenting and communicating client questions, concerns, and progress is necessary to ensure the highest level of care. You will find effective communication with your supervisor can significantly improve your client’s outcomes.
RBT Task E-1: Effectively communicate with a supervisor in an ongoing manner
Open and ongoing communication with your BCBA or direct supervisor is crucial. Your BCBA or BCaBA must supervise you at least 5% of your direct hours (i.e., If you work 25 hours per week, your BCBA would supervise 5+ hours a month). However, effective communication extends beyond supervision sessions. You should expect to communicate with your supervisor(s) outside of therapy sessions with questions, concerns, and updates as they come up.
Feedback is a key component of an RBT’s role. It’s important to take feedback well, be receptive to your supervisor’s guidance, and modify your performance as directed. Keep in mind that the main benefit of feedback is to improve your learner’s therapy progression. Getting feedback on areas you can improve on should not be taken as a personal offense but rather as guidance for what to change to help your clients make more progress.
Don’t forget feedback goes both ways! Just as your supervisor provides you feedback, you should also give feedback to them. Communicate with them when you have questions or concerns or could use more support. Be direct but respectful and professional in all communications. For example, if your supervisor does not provide clear instructions on how to conduct a new program, you could say, “I don’t quite understand how to implement this goal. Could you demonstrate it for me?”
RBT Task E-2: Actively seek clinical direction from a supervisor in a timely manner
Always seek guidance from your supervisor in a timely manner. If you are ever unsure how to conduct a goal or implement a plan, wait until your supervisor provides you with guidance before implementing it. Conducting the program before your supervisor provides clarification can do more harm than good if you inadvertently do something wrong.
A “timely manner” is subjective. You must use clinical judgment to determine how urgent something is. If you’re ever unsure whether or not to communicate something urgently, err on the side of caution and notify your supervisor right away.
There are countless examples of when you need to seek clinical direction from your supervisor. Here are a few scenarios in which you would seek guidance from your supervisor:
- Your client demonstrates a new (challenging) behavior: The urgency will depend on the type of behavior. If it was harmful or significant in some way, notify your supervisor right after the session. Be sure to also document the behavior in your session notes. If your client exhibits a new behavior you are concerned about, but it is not harmful or dangerous, still document it. However, you may be able to wait until your next overlap to discuss it with your supervisor, or you can send a secure email about it.
- Your client’s challenging behavior significantly increased, or they did not respond well to the strategies in their behavior plan: Again, the urgency of your communication will depend on the significance of the behavior.
- You are unsure how to conduct a goal or behavior plan strategy: Communicate with your supervisor before your next session.
- You need stimuli, data sheets, or other materials: Communicate with your supervisor before your next session if you’re entirely out of the item. Try to communicate with them before you are completely out of materials, though!
- There are barriers preventing progress: Communicate with your supervisor if you notice barriers preventing you from implementing goals or preventing your client from succeeding. For example, your client’s sibling stays in the therapy space throughout the session, interfering with your ability to implement goals.
RBT Task E-3: Report other variables that might affect the client in a timely manner
Notify your supervisor in a timely manner of any variables that could affect your client’s progress or well-being, including factors that your client’s family, caregivers, or other service providers communicated to you.
Some of the variables that you should inform your supervisor of include:
- Your client is sick
- Your client is experiencing sleep disturbances (e.g., unable to fall asleep or stay asleep at night, falling asleep during sessions)
- Your client’s household situation has changed or will soon (e.g., parents separated, a family member moved in or out, the family is moving to a new location)
- Your client is starting a new medication or has a change to their current meds
- Your client is starting or stopping other therapies
- Your client’s caregiver reported questions or concerns to you
- You observe or suspect abuse or neglect—this should always be reported immediately to your supervisor and to the appropriate authorities (e.g., CPS, DCS). Remember, RBTs are mandated reporters.
Again, the time frame for when to report these variables to your supervisor will depend on the urgency of the situation. For example, if your client is sick and it is affecting your session (i.e., your session is canceled or is ending early), you should communicate this with your BCBA right away. If the situation is less urgent, such as your client is starting occupational therapy next month, you can wait to inform your supervisor of this until your next overlap.
RBT Task 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
RBTs write daily session notes for each client’s session. You will write session notes to provide a recap of the session. Generally, you’ll include the following information in your session note:
- Your name and credentials
- The date and times of the session
- The skills and behaviors you targeted
- How the client responded to treatment
- Data from the session (e.g., behavior data, program scores)
- Barriers to the session
- Pertinent information shared with you by the parents or caregivers
Session note formats will vary depending on the local laws, funder requirements, and your organization’s regulations. Be sure to follow the requirements your organization sets forth for note writing. Each company will also have different guidelines for when to complete your session notes. However, it is vital that notes are written as soon after a session as possible. This is because our memories naturally fade as time goes on, reducing the likelihood that the note will be accurate if we wait too long to write it. The best practice is completing the note at the end of the session. However, most organizations set a rule of completing notes within 24–48 hours.
Remember, your notes are a part of your client’s medical history. As such, session notes should always be written objectively and professionally. Include only observable and measurable information. Don’t include subjective language like “client was happy” or “client didn’t want to work today” (unless the client directly told you these things). Session notes are typically read by your supervisor, other RBTs on the team, and parents/caregivers. However, they may also be read by the insurance funder, the head(s) of your company, or others who have consent to do so. Thus, don’t write anything you wouldn’t be comfortable with numerous people potentially reading.
RBT Task E-5: Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements
Safeguarding client data is crucial. RBTs must follow all local and federal laws regarding the collection, storage, and transportation of client’s data and other sensitive information.
One of the most important laws is the Health Insurance Portability and Accountability Act (HIPAA). This is a federal law requiring healthcare providers to safeguard clients’ protected health information (PHI). Patient information must always be confidential, and providers must take measures to avoid any deliberate or unintentional unauthorized release of information. Data sheets, session notes, and any other client documentation should always be placed in a secure location. Many companies now use HIPAA-compliant software for data collection and session notes. These online systems can reduce the chances of PHI breaches that may be more likely to occur with the transportation of paper documents.
If you are ever responsible for transporting client documentation, you must take great care to keep it safe. At a minimum, it needs to be in your locked trunk. Ideally, it should be inside a locked box in your locked trunk for double security. If you use an online system for data collection, the device must have a passcode that is not shared with unauthorized individuals. You should not take data on your personal device or keep client documents in your home where others may come into contact with them.
RBT Documentation & Reporting Quiz
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Question 1 of 6
Which of the following is true of feedback?CorrectIncorrect
Question 2 of 6
Of the following scenarios, which situation would you notify your supervisor of immediately after the session?CorrectIncorrect
Question 3 of 6
Hazel arrives at her client’s therapy session at 8:30 AM. When she walked in, the client’s mom began apologizing and explaining that the client was up all night and was ill, so they would need to cancel the session. When should Hazel notify her BCBA of the cancelation?CorrectIncorrect
Question 4 of 6
Which of the following describes how you should write session notes?CorrectIncorrect
Question 5 of 6
Which of the following would not be included in a daily session note?CorrectIncorrect
Question 6 of 6
What federal law requires healthcare providers, including RBTs, to ensure the confidentiality of patient information?CorrectIncorrect