E. Documenting and Reporting
E. Documenting and Reporting
Embedded Files
E.1. Effectively Communicate with a Supervisor in an Ongoing Manner
E.1. Effectively Communicate with a Supervisor in an Ongoing Manner
Tips:
Set up a regular check in.
Ask when you need help!
Share when there are changes!
E.2. Actively Seek Clinical Direction From a Supervisor in a Timely Manner
E.2. Actively Seek Clinical Direction From a Supervisor in a Timely Manner
Notify your supervisor when something is not going well!
Be willing to learn!
E.3. Report other variables that might affect the client in a timely manner.
E.3. Report other variables that might affect the client in a timely manner.
Examples:
Examples:
Caregiver Report
Changes in Medication or medical event
Changes in the environment
Changes in Behavior
**Be Trauma Informed-see trauma section**
**Be Trauma Informed-see trauma section**
E.4. Generate Objective Session Notes for Service Verification by Describing What Occurred During the Session, in accordance with applicable legal, regulatory, and workplace requirements
E.4. Generate Objective Session Notes for Service Verification by Describing What Occurred During the Session, in accordance with applicable legal, regulatory, and workplace requirements
How to Create a Session Note
How to Create a Session Note
Session Content
Session Content
Location
Programs Run
Overview of the behaviors observed
Any progress toward goals
Any discussions with caregivers surrounding treatment
Others Present
Others Present
Family Members present
School Staff/ Classmates
Additional participants
Any other therapists or supervisors
Client Variables
Client Variables
Diagnoses
changes in health
Changes in Medication
Changes in Routine
Skill Access Day (overall how are they feeling)
Modifications and Plan
Modifications and Plan
Write "Follow protocol written by BCBA"
DON'T FORGET TO SIGN YOUR CASE NOTE!
DON'T FORGET TO SIGN YOUR CASE NOTE!
It is not valid if you skip this step
Creating a Session Note
Creating a Session Note
SOAP
Subjective
Objective
Analyze
Plan
E.5. Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements
E.5. Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements
Must Comply with HIPAA policies and regulations
HIPAA requires that a client's data and paperwork and identifying information be kept confidential and protected.
Store client data sheets, session notes, and paperwork in a secure location.
You should always put them back after a session so that they are kept in that safe location (if paper documentation).
Log out of all online platforms when finished and have secure passwords.
If you provide home-based services, it is imperative that you be careful when traveling with client documentation.
Carry as little client data as possible and store it carefully by locking it in a travel briefcase and possibly even in a trunk.
Be mindful of confidentiality laws
Be familiar with all state and federal laws
Report any incidents that you think abuse or neglect could occur.
No need to investigate a possible occurrence of neglect/abuse, but to report to responsible authority agency (You are a Mandated Reporter)
Be sure to document your observations professionally in all necessary locations.
This training program is based on the RBT Task List (2nd ed.) and is designed to meet the 40-hour training requirements for RBT Certification. The program is offered independently of the BACB.
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