Session notes are a crucial part of medical documentation. They enable practitioners to record every germane detail of a session, aiding in more informed decision-making for their client’s treatment. Practitioners of Applied Behavior Analysis (ABA) use session notes to communicate with funders and payors, but also to reflect on what happened in the session. Behavior Analysts will peruse the notes of the direct staff, and behavior technicians, to better understand how their clients are progressing. ABA often involves a cross-functional team of therapists, parents, and caregivers who work together to develop the most effective intervention plan. Session notes play a crucial role in facilitating this collaboration and ensuring it is impactful.
What are Session Notes in ABA?
Session notes are detailed reports that allow the practitioner or technician to thoroughly and conveniently document the specifics of a session. These notes include patient details, intervention goals and strategies, client progress, and a narrative summary of the session. The descriptions in session notes are objective and free of personal judgments or opinions. They provide a literal and detailed record of the learner’s behavior, mood, progress, and any environmental changes that may influence these factors.
The session notes are later analyzed and reviewed by supervisors in conjunction with data and graphs to ensure that interventions and treatment plans are comprehensive and effective.
Significance of Session Notes
Session notes are essential for the effectiveness of ABA. Without a detailed record of the client’s progress and their positive or negative responses to specific interventions, planning the next steps and achieving significant improvement would be challenging. Additionally, these notes are invaluable for all stakeholders involved in the client’s care, including parents, siblings, partners, payors, and caregivers. They provide insight into the learner’s behavior—its function, triggers, and reinforcers—and lead to a better understanding of how to address and overcome challenges.
Here are some reasons why session notes are an indispensable part of ABA:
Effective Treatment Plans
Session notes provide a detailed record of the session, making them a valuable resource for analyzing the client’s behavior, identifying patterns, and tracking progress or regression. This information is essential for informed and effective decision-making. It allows practitioners to adjust treatment plans to target the individual’s unique needs, avoiding the time-consuming and often ineffective trial-and-error approach of implementing a general plan. Generally session notes include the data collected in the session and may include graphs for visual analysis.
Cross-Functional Collaboration
Session notes are easy to read and understand as they are a record of the session. This makes it easier for other professionals and parents or caregivers to collaborate with the behavior analyst and learn about the behavioral patterns and developments of the learner.
Ethical Practice
Board Certified Behavior Analysts ® are beholden to an ethics code published by the Behavior Analyst Certification Board ®. Throughout this code are references to proper documentation as it is a hallmark of behavior analysts’ ethical behavior. In fact, a seminal article in behavioral science, Some Current Dimensions of Applied Behavior Analysis (Baer, Wolf & Risley, 1968) lists technological as one of the seven dimensions of ABA. It notes that techniques and processes of behavior analysis must be completely described so that another practitioner can produce the same results.
Medical Record
Session notes are a legitimate part of a person’s medical record. This means that if the client relocates or chooses a different practitioner, the new behavior analyst can review previous sessions and note any developments or challenges. Having access to such comprehensive records of a patient’s medical history enables practitioners to easily transfer patients.
Insurance Authorization
Lastly, session notes play a crucial role in convincing insurance companies why a treatment was medically necessary and beneficial for the client. Without this documentation, they may not approve coverage for the treatment.
Tips for Writing Expert ABA Session Notes
Since session notes are a vital part of ABA, it is important for behavior analysts and technicians to focus on how they are written. Session notes may be read by multiple professionals to better understand the client’s behavior and progress and combine their expertise to reach effective treatment solutions. Hence, whether session notes are helpful or not, depends on the way they are written. Here are some tips for good ABA session notes:
Write Immediately After the Session:
It is best to record the details of the session while they are still fresh, to ensure no information is missed. As good practice, fifteen minutes right after the session can be set aside to complete session notes.
Use a Template:
Session notes have a number of components and are meant to be very detailed. Using a well-structured template can efficiently organize all of the important information, and make it easier to find specific details. Additionally, using a template ensures the author has covered all the details and helps them keep their notes precise and relevant.
Maintain a Professional Tone:
Session notes should be written in a professional manner as they are an official medical record and are reviewed by multiple professionals and insurance companies. It is best to avoid informal abbreviations, casual language, and typing/spelling errors.
Match Detail to Session Length and Complexity:
The session notes should be an accurate record of the session. If the sessions are long and complex with multiple challenges identified or overcome, the notes should reflect that by being comprehensive and inclusive of all details. If the session is a short followup, the notes may be more concise.
Go Digital:
Electronic documentation is a better alternative to manual note-taking. It eliminates the challenges of legibility, can leverage spellcheck and other features to ensure the notes are free from typing or grammatical errors, and is easier to store and access than paper copies.
Additionally, ABA practice management software can also assist with keeping all the information organized and integrate the session notes seamlessly with data collection and patient records.
Going digital helps with auditing notes or reviewing notes within a date range. Motivity’s Bulk Download Feature is one of the best audit tools out there and is very easy to use as well. The practitioner only has to select the patient and a date range to extract an organized and structured report. In addition, they are HIPAA compliant, keeping your client’s information safe.
These tips may seem simple but they can make any session note thorough and professional while remaining compliant with all insurance standards.
Conclusion
Session notes are a crucial component of ABA, as they document the details of each session to track the client’s progress and maintain effective treatment plans. They facilitate collaboration among behavior analysts and other professionals, ensuring that the client receives optimal care and shows improvement more quickly.
