This RBT exam study guide page covers documentation and reporting, outlined in Section E of the RBT task list. It’s an essential topic in applied behavior analysis, and ten questions will be asked in the final RBT exam.
- Significance of Documentation and Reporting in ABA: ABA is data-driven, and documentation and reporting are essential for tracking progress, evaluating interventions, and ensuring consistency in treatment plans. An RBT must document everything and report to the supervisor to improve the therapy outcomes.
Effectively Communicate With a Supervisor in an Ongoing Manner
As a Registered Behavior Technician, you must communicate with your supervisor in an ongoing manner. Your BCBA or BCaBA must supervise you at least 5% of your direct hours.
For example, if you work 20 hours a week, your BCBA must supervise for 4+ hours a month.
You should discuss the challenges with your supervisor outside the therapy session. Your supervisor will listen and change intervention plans to improve the progress. Be open to feedback and guidance from your supervisor.
Also, an RBT must be respectful and professional in all communications. If your supervisor doesn’t provide clear instructions, you can politely ask to demonstrate it.
Actively Seek Clinical Direction From a Supervisor in a Timely Manner
Your supervisor is more experienced, and you should seek his/her guidance on time. If you’re unsure about implementing a behavior intervention plan, wait for your supervisor’s instructions. Sometimes, implementing a plan with the wrong approach can do more harm than good.
There are countless examples of where you need your supervisor’s guidance. Here are a few scenarios where you should seek advice from your supervisor:
- Your client demonstrates a new (challenging) behavior: If your client shows a new challenging behavior that is harmful or dangerous while implementing the intervention plan, you should document it in your session notes and report it to your supervisor right after the therapy session. But, if your client shows a new behavior you’re concerned about but is not harmful or dangerous, you should document it and wait until your next meeting to discuss it with your BCBA.
- Your client’s challenging behavior significantly increased: If your client’s challenging behavior has increased considerably after a few therapy sessions, you should notify your supervisor. The urgency of communication depends upon the significance of the behavior.
- You are unsure how to conduct a goal or behavior plan strategy: If you’re uncertain about implementing a behavior intervention plan for your client, you must communicate with your supervisor before the next session.
- You need stimuli, data sheets, or other materials: Proactive communication with your supervisor is essential when you require stimuli, data sheets, or other materials for your sessions. If you anticipate running out of crucial items, it’s advisable to notify your supervisor beforehand to ensure timely replenishment.
- There are barriers preventing progress: When you encounter barriers hindering progress in therapy, such as external factors like a client’s sibling disrupting sessions, it’s crucial to communicate with your supervisor. Your supervisor can guide you in addressing the situation, whether setting boundaries, altering the therapy environment, or involving other stakeholders.
Report Other Variables That Might Affect the Client in a Timely Manner
You should notify your supervisor about other variables that affect your client’s progress. A BCBA will guide you to handle such a situation.
Here are some external variables that you should inform your supervisor of:
- Your client is experiencing sleep disturbances.
- Your client is sick.
- 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 changing their current meds.
- Your client is starting or stopping other therapies.
- Your client’s caregiver reported questions or concerns to you.
- If you observe or suspect abuse or neglect, it should always be reported immediately to your supervisor and the appropriate authorities (e.g., CPS, DCS).
The time period for when to report to your supervisor will depend upon the situation’s urgency. For example, if your client has a fever or he/she is sick and it affects your therapy sessions, you should inform your BCBA immediately. On the other hand, if your client will start occupational therapy next month, you can wait until your next meeting with your supervisor.
Generate Objective Session Notes for Service Verification by Describing What Occurred During the Sessions in Accordance With Applicable Legal, Regulatory, and Workplace Requirements
Registered Behavior Technicians write daily session notes for each client. It provides a recap of the previous session. The session note format includes the following information:
- Your name and credentials
- The date and time of the session
- The skills and behavior you targeted
- How the client responded to treatment
- Barriers to the session
- Data from the session (e.g., behavior data, program scores)
- Relevant information shared by the parents or caregivers
The session note format varies on your organization’s regulations and local laws. You should follow your organization’s requirements in note writing. Some organizations have different guidelines for when to complete your session notes.
It’s recommended that you complete your session notes right after the therapy session because our memories naturally fade as time goes on. Most organizations set a rule of completing session notes within 24 to 48 hours.
Please remember that the session notes are your client’s medical history. You should write it objectively and professionally because your supervisor, RBTs on the team, parents, and caregivers will overview it periodically.
Only include the observable and measurable information in your session notes. 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).
Comply With Applicable Legal, Regulatory, and Workplace Data Collection, Storage, Transportation, and Documentation Requirements
Keeping client data safe is essential. As RBTs, you must follow all the rules about collecting, storing, and moving around client information. This includes following local and national laws, like the Health Insurance Portability and Accountability Act (HIPAA), in the U.S.
These laws ensure you keep your clients’ personal info private and secure. By following these rules carefully, we protect our clients’ privacy, maintain their trust, and avoid any problems with unauthorized access to their information.
Many companies now use HIPAA-compliant software and tools to collect data and write session notes. These online tools make it less likely that private client info will be accidentally shared or lost, like what might happen with paper documents.
Using these tools can better protect your client’s privacy and keep their information safe from unauthorized access.
