We all know that ABA session notes are a necessary evil. After a tiring session (both physically and mentally), the last thing our RBTs want to do is to sit down and write what happened. Anyone who has been audited by an insurance company knows to make sure their session notes are always tip top. A well-written session note goes a long way to helping BCBAs and BCaBAs appropriately adjust programs and improve learning opportunities for the learner.
Describe
What does a good ABA session note look like?
So how do we get to that perfect session note? Well, first we must describe it!
- A good session note has enough information for the BCBA and the payor to get a sense of what happened in the session but isn’t so long that it’s difficult to read and write.
- A good session note has comprehensive data from all of the programs run at the session in a manner that is easy to visually assess.
- A good session note has all of the required elements – date, location, signatures, etc.
Now that the skills are identified, it’s time for the training. The elements of Behavioral Skills Training are giving instructions, modeling, rehearsal, and feedback. For session notes, clear instructions are a must. Having a good template is important, but knowing how to fill it out isn’t always obvious. Creating a checklist for your RBTs to follow will ensure that critical steps are not missed.
Did you know Motivity allows for multiple session note templates and the ability to easily copy and modify them when requirements change?
Model
Show Examples and Non-Examples
When training an RBT (or BCBA) to write a session note, providing sample notes that demonstrate all the necessary components is really helpful, but you might not think of showing non-examples. Non-examples are models of what NOT to do or write in an ABA session note. This will help highlight the errors to look out for or areas in your session note that could be rejected or flagged. Keep in mind that you may need multiple exemplars and you may need to keep revising the model as different nuances are needed for different clients; not to mention that insurance companies have different priorities. The session note outline will need to be tweaked depending on the payor.
Practice
Have them review sample notes to identify errors.
Most BCBAs spend a lot of time training their RBTs on the specific programs for the client with whom they will work, but do they spend equal time training them on how to write a clear and comprehensive session note? Session note training should be incorporated into initial training, and then practiced until it becomes second nature, thereby cutting down on the time it takes to create the note. One way of training staff on session notes is to have them review sample session notes and see if they can find mistakes and errors in other session notes. If they can identify correct and incorrect entries, that is a good indication that they can identify errors in their own notes.
Feedback
Finally, feedback and reinforcement are paramount to honing the skill. Many companies do public posting on key elements of the session note due to its importance. Some have reinforcement programs that focus on specific parts and therefore see an increase in those behaviors!
However you intend to teach your RBTs to achieve the perfect session note, you will benefit from electronic data collection and automatic transfer of your client’s data to a session note that meets all your needs. So the next time you find yourself pulling out your hair because your ABA session notes aren’t perfect, try a little behavioral skills training and put yourself at ease!
