How to Write ABA Session Notes (Tips & Templates) For RBTs BCBA & BCaBA

Do you find it wearisome to jot down notes after every patient session? Are you having a tough time understanding what RBT and ABA notes entail? If you’re perusing this blog, it’s possible that your answer is yes!

Whether you’re an Registered Behavior Technician or any other kind of therapist, you've probably been jotting down notes ever since you started practicing. However, you may not have received proper guidance on how to efficiently craft them to provide maximum value to your client's interdisciplinary team.

Or, you might be an expert when it comes to your notes, but you’re still searching for that extra missing piece! Don’t worry, you’re not alone, we understand your frustration and have devoted this article to guide you.

That is, despite the fact that documentation has been in existence for over fifty years, it's not always easy to capture clients’ pertinent information succinctly and in a timely manner.

Not only so, but comparable to other domains of human services and the medical sphere, accurate and impartial documentation in ABA therapy holds a pivotal position among your job responsibilities in guaranteeing that services are appropriately documented, procuring financial compensation for rendered services, and allowing others to scrutinize and evaluate your services.

To that end, this blog will cover the following topics:

• Overview of RBT and ABA therapy
• Importance of note-taking
• Key elements of RBT and ABA notes
• Best practices for RBT and ABA note-taking
• Common pitfalls, challenges, and solutions for crafting effective notes
• Compliance and legal considerations
• Extra tips to shine

Setting the Ground: Overview of RBT and ABA therapy

Applied Behavior Analysis (ABA) is a form of therapy designed to address communication issues, motor skill deficits, and behavioral disorders. The ABA has been recognized by the American Psychological Association as an evidence-based practice after it was well supported by peer-reviewed literature as a form of treatment.

Registered Behavior Technicians (RBT) and other ABA service providers refer to ABA guidelines designed for the treatment of individuals who learn and think differently, for example, those who have been diagnosed with an autism spectrum disorder as well as those with behavioral and developmental challenges.

To start with, it is worth noting that ABA notes are different from other therapy progress and counseling notes. Let’s elaborate. You have probably come across several different treatment approaches when tackling behavioral therapy: ABA, BCBA, etc. But what does it all really mean?

Applied Behavior Analysis (ABA) is a methodological approach aimed at studying behavior to identify the most fitting behavioral interventions. While ABA therapy is not confined to addressing autism, it is commonly employed in treating children with autism spectrum disorder (ASD). When implemented with a high level of quality and intensity, ABA has proven to be a well-established and efficacious therapeutic modality for ASD.

The ABA framework is characterized by a strong emphasis on positive reinforcement as a means of bolstering desirable behaviors and honing the skills of the child. Through this strategy, the ultimate objective of ABA therapy is to help the client develop desirable skills that will promote independence and success in the short and long term.

ABA therapy is widely employed in various settings, including clinics, hospitals, schools, and homes. For instance, parents may incentivize their children to clear the table after meals with rewards. By breaking behaviors down into this sequence, Registered Behavior Technicians and other ABA therapists can pinpoint targeted changes in an individual's environment, response, and reward system to enhance key skills.

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There exist manifold differences between ABA and BCBA therapy. While an ABA therapist imparts applied behavior analysis therapy to an individual, a BCBA, being a board-certified individual, is equipped with the training to proffer and supervise behavior analysis. Frequently, it is a BCBA who oversees individuals providing ABA. It ought to be noted that, by definition, neither ABA nor BCBA is exclusively tailored for Autism; rather, their specialization lies in the realm of behavior.

Why Is Note-Taking Imperative Across-The-Board?

Not only do ABA and RBT notes help organize clients’ sessions, but they are also crucial when creating actionable treatment plans, tracking clients’ progress, identifying trends and patterns in behavior, and making informed decisions that can be shared with interdisciplinary team members.

The notes you take during ABA therapy sessions serve multiple further purposes, including substantiating billing claims for insurance agencies as well as communicating your rationale for ongoing services. Let us elaborate: the burgeoning field of behavior analysis has undergone a meteoric rise in popularity over the past two decades, largely due to its proven efficacy as a treatment for individuals diagnosed with an autism spectrum disorder. This has been paralleled by a concomitant surge in demand from both state and private insurance companies to provide coverage for behavior analysis-based services. Nevertheless, with this increased funding comes a commensurate uptick in documentation requirements. To that end, notes serve as a comprehensive record of billed sessions, evidence of the necessity of therapy, documentation of response to treatment, coordination of care, and notation of other important events.

Add to the above, ABA and RBT notes allow for objective and measurable observations. which makes them an essential component of the documentation process. For example, if a client diagnosed with narcolepsy inadvertently falls asleep during your therapy session, one cannot simply assume the client is tired. Rather, you should appropriately document such events to ensure proper services.

As such, taking meticulous and accurate ABA and RBT notes seems paramount across every aspect of behavior analysis practice.

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Answering the “How-To”

RBT and ABA note not much different than other progress notes taken by mental health clinicians. While the specifics of what should be included in RBT and ABA notes may vary by company, common elements often encompass the therapist and client names, session date and time, teaching techniques utilized, client's reaction to therapy, coordination of care, and the therapist's signature. Keep in mind that the notes produced by behavior analytic technicians carry a particular significance to supervisors and other investing parties: these notes not only provide clinical data on the therapeutic programming executed during the session but may also serve as the sole documentation of services provided to a client on a given day. As such, one must be careful when drafting such notes.

ABA Session Note Checklist

When compared to other progress notes in psychotherapy notes, RBT and ABA notes must include imperative elements such as:

• the patient's full name and date of birth
• the date of service
• the session’s start and end time
• the location of service, whether at home, office, school or through telehealth
• a concise but comprehensive narrative describing the therapy and targeted goals
• the specific behaviors observed: the therapist must provide a nuanced understanding of the client’s general behavior, particularly in the context of socially impaired ABA learners. During each session, the therapist should note ABC data, including the physical characteristics of the behavior, what prompted such behavior, its frequency, duration, and its immediate aftermath. This information helps in the precise formulation of effective strategies.
• the interventions used and the outcomes of such interventions: the therapist must document the ABA goals whether reached or failed by the learner; recording the success achieved when a learner completes a program to the targeted level. Conversely, if a learner fails to reach the intended target, the therapist should note this failure and adjust the subsequent sessions to focus on mastering those goals.
• the individual rendering the service must provide a legible full legal signature to authenticate the session notes.

Finally, a therapist must remain vigilant and avoid complacency, as each session presents unique challenges and opportunities. Therefore, additional notes on unusual patterns of behavior, new behaviors, materials used and incidents requiring the supervisor's attention are of utmost importance to create tailored strategies for each learner.

This short video will surely help you learn more about ABA notes: Methods, Tips, & Tech

Top Practices and Requirements for RBT and ABA Session Note-Taking

The records of your encounter with the client and the documents produced during the process are of an enduring and legally binding nature. Therefore, it is of paramount importance that they fulfill the following criteria: readability, precision, punctuality, lucidity, brevity, comprehensiveness, and veracity.

To elaborate, your notes must be:

• Clear: avoid the use of extravagant verbiage that obfuscates the message of the sentence.
• Complete
• Accurate: when crafting session notes, RBTs must keep in mind that these notes will be a permanent record of the client's progress, necessitating accuracy and professionalism in writing.
• Concise: be specific and avoid unnecessary details
• Timely: realistically, it is advisable to allocate approximately ten minutes for jotting down your notes for a 45-minute session. Try to complete your notes within 24-72 hours after your sessions (depending on your insurance requirements) to avoid ending up unable to remember your session’s details.
• Objective: it is imperative to complete session notes objectively and professionally by strictly disclosing facts and actual information, as opposed to incorporating subjective elements such as personal thoughts and feelings.

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Here are some suggestions to enhance the professionalism of your documentation:

• Emphasize active voice: avoid verbiage that portrays you as a passive spectator. Remember that you are a competent clinician and provide a critical service. Use active verbs. For example, instead of writing "the RBT observed Sarah perform the task", write "the RBT taught Sarah how to perform the task”.
• Improve readability: notes serve as a valuable reference tool for other healthcare professionals to retrieve information rapidly. Use headings to increase readability, particularly for lengthy notes that describe a complicated or extended session.
• Employ bulleted lists and tables judiciously in cases where they are fitting: tables are efficacious in rapidly conveying significant information.
• Solely adopt standardized abbreviations: utilizing abbreviations that are familiar to Board Certified Behavior Analysts (BCBAs) and other healthcare practitioners is okay (although not preferred). On the contrary, the application of intricate or unconventional abbreviations can confuse other practitioners.
• Proofread: despite your best efforts, errors are bound to occur. Simple grammatical mistakes detract from the professional appearance of your writing. Allocate a few minutes to review and refine your work.
• Use templates: ready note templates can expedite the note-taking process, foster efficiency, and promote structure whilst guaranteeing the comprehensive documentation of pertinent information. A plethora of note templates is accessible for selection when crafting intake, treatment, progress, and other notes, among them, the widely utilized S.O.A.P. template in ABA therapy. Nevertheless, it behooves to highlight that no universal framework exists for drafting progress notes. Hence, the onus rests upon the individual to select the template that optimally aligns with their requirements: SOAP, DAP, GIRP, BIRP, etc.

ABA Notes: SOAP Template

The ABA SOAP notes template is ****the most widely used template in ABA therapy (among others such as DAP, GIRP, BIRP, etc.) and is comprised of four distinct components, namely the Subjective (S), Objective (O), Assessment (A), and Plan (P) sections, which together provide a comprehensive and holistic overview of the client's progress and session.

• The Subjective (S) Section: serves as a platform for the patient to express their condition, without any measurements or objective data. The use of direct quotes from the client is necessary to ensure accuracy. Social and family history, if pertinent, may also be included.
• The Objective (O) Section: presents measurable data and factual observations, including physical and psychological behavior, general appearance, and client engagement level.
• The Assessment (A) Section: synthesizes the information from the subjective and objective components to evaluate the client's progress and highlight any patterns or themes observed. This section is crucial in identifying any changes from the previous session, providing differential diagnoses for new symptoms, and explaining client responses to interventions.
• Finally, the Plan (P) Section: outlines the necessary interventions and strategies needed for the client's continued progress, including short-term goals and medications. The section provides a reflection on the effectiveness of previous strategies and details the next course of action for upcoming sessions.

Behold, an exemplary ABA SOAP note template chronicling the therapeutic journey of a client with autism. Remember to sign your note if you are following this template:

Client Information:

Common Pitfalls, Challenges, and Solutions for Crafting Effective Notes

Crafting high-quality ABA notes requires time and practice. Even seasoned therapists can make common mistakes as they learn, such as employing informal and/or judgmental language.

To improve the quality of your notes, it is advisable to avoid common mistakes such as:

• Misattributing statements: Instead of using vague words such as "seemed" or "appeared," record the exact statements as made by your client. For example, writing "the client stated he was in a good mood” is way better than writing “the client seemed to be happy”.
• Use language that conveys objective, professional observations. Avoiding certain language practices will help ensure that your notes are clear and concise, and maintain a high level of professionalism. Avoid using judgmental or opinionated language. Instead of labeling someone as "obnoxious" or "annoying", focus on specific behaviors or actions. For example, writing "the client interrupted frequently during the session" is more informative than labeling them as "annoying".
• Another pitfall to avoid is making subjective statements without empirical evidence. Rather than stating that "Joe was frustrated", describe the specific observations that led you to that conclusion. Employ descriptive language that captures observable behaviors, such as “Joe slammed his fist on the table when he talked about his issues at work”.
• Refrain from using language that is vague or subjective, such as "seems" or "appears," as this could alter the interpretation of objective observations. Instead, rely on factual and descriptive language that accurately depicts the incident, such as "the client yelled at her partner".
• Avoid idioms and informal language. Your notes will be used by colleagues and insurance providers to evaluate your work. Hence, a formal tone is necessary.

ABA Session Notes for Insurance (Compliance and Legal Considerations)

ABA notes serve as a testament to the discerning eye of any Registered Behavioral Technician, attesting to their astute observations and interventions during therapy sessions. These notes facilitate a seamless exchange of information among healthcare professionals, enhancing the efficacy of patient care. More importantly, the meticulous documentation contained in those notes substantiates the authenticity of insurance claims and ensures regulatory compliance during audits.

In the context of Applied Behavior Analysis (ABA), the practice of precise documentation is indispensable for effective patient care. Given that patients often receive treatment from multiple therapists and medical practitioners, accurate and comprehensive records are essential for coordinating care across various disciplines. Failure to maintain such records can result in distorted information, ultimately impeding the delivery of optimal care to the patient, the reason why there are special legal considerations to be kept in mind: it is imperative that your notes are meticulously crafted to satisfy the requirements of both insurance companies and state regulatory bodies. In order to be fully compliant, your notes must meet, at a minimum, the following requirements, in addition to any state-required components:

• Your notes should include the date, time, location, provider's name, client's name, and date of birth.
• Third-person writing and therapist names may be required by some insurance companies.
• The minimum elements required for compliance include patient name, date of service, type of service, start and end times, problem statement, medical necessity support, person-centered detail, patient observation, the rationale for exposure assessments, progress summary, protocols used in treatment, and coordination of treatment with other healthcare providers or service organizations.
• The patient's name and date of service should be documented on each page of the record.
• The type of service provided, such as diagnostic assessment or group psychotherapy, should be included.
• Start and end times should also be recorded to provide a clear timeline of the therapy session.
• The problem statement should contain the diagnosis and provide context for the therapy.
• Medical necessity support should be included to justify the therapy provided and its effectiveness.
• Person-centered detail such as behavior descriptions or quotes can help illustrate the patient's progress.
• Patient observation should be documented to note any changes in behavior or progress.
• The rationale for exposure assessments and interventions should be included, along with any safety measures taken.
• A summary of progress or lack thereof should be included, with changes to the plan of care made as necessary.
• Protocols used in treatment should be documented, along with any modifications made to them.
• Finally, coordination of treatment with other healthcare providers or service organizations should be recorded to ensure a comprehensive approach to care.

Final Note: Get the Help You Need

Assistive services are indispensable to ABA therapists, whose demanding role entails tedious and arduous administrative obligations, which can detract from the precious time devoted to their clients. Mentalyc, an innovative note-taking app, alleviates this burden by allowing ABAs to concentrate on their clients while ensuring the smooth functioning of their practice's administrative aspects. This state-of-the-art app employs intelligent technology to generate comprehensive and accurate notes without the need for manual transcription. By utilizing Mentalyc, ABAs can bypass the chore of note-taking and eliminate the risk of error, thereby maximizing their time and energy for the benefit of their clients.

References

• Devita-Raeburn, E. (2016, August 10). The controversy over autism’s most common therapy. Spectrum News. Retrieved from https://www.spectrumnews.org/features/deep-dive/controversy-autisms-common-therapy
• Team, G. T. E. (n.d.). Applied Behavior Analysis (ABA). Applied Behavior Analysis. Retrieved from https://www.goodtherapy.org/learn-about-therapy/types/applied-behavior-therapy
• What is applied behavior analysis? (n.d.). Child Mind Institute. Retrieved from https://childmind.org/article/what-is-applied-behavior-analysis

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About the author

Salwa Zeineddine

Salwa Zeineddine is an expert in the mental health and medical field. She has extensive experience in the medical field, having worked as a medical researcher at the American University of Beirut. She is highly knowledgeable about therapist needs and insurance requirements. Salwa is passionate about helping people understand and manage their mental health, and she is committed to providing the best possible care for her patients. She is an advocate for mental health awareness and works to ensure that everyone has access to the resources they need.

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