ABA of North Texas

Note Taking Policy

  1. Purpose: Session notes are an essential tool for tracking client progress, communicating with team members and caregivers, and maintaining a record of interventions and outcomes.
  2. Scope: These standards apply to all ABA therapy sessions conducted at ABA of North Texas, including individual and group sessions. Behavior therapists and Board Certified Behavior Analysts (BCBAs) are responsible for adhering to these standards.
  3. Documentation Format: Session notes will be documented using the electronic health records (EHR) system provided by ABA of North Texas. The EHR system ensures standardized documentation and efficient record-keeping.
  4. Content Guidelines: Session notes must include the following components:
    • Date, time, and duration of the session
    • Participants present (therapist, client, caregivers, etc.)
    • Goals and objectives targeted during the session
    • Interventions and strategies used
    • Behavior observations and data collected
    • Progress made toward goals
    • Notable incidents or challenges
    • Client's response to interventions
    • Next steps or recommendations for future sessions
  5. Objectivity and Clarity: Session notes must be objective and clear, using precise and factual language. Avoid subjective interpretations, assumptions, or value judgments.
  6. Timeliness: Session notes should be completed immediately after the session. Prompt documentation ensures accurate recall and minimizes errors.
  7. Confidentiality and Privacy: Maintain strict client confidentiality and privacy when documenting session notes. Ensure that the EHR system is securely accessed and that physical records are stored appropriately.
  8. Review and Supervision: BCBAs will conduct regular reviews of session notes to ensure accuracy and alignment with treatment plans. Feedback and guidance will be provided to behavior therapists as needed.
  9. Communication: Summaries of session notes will be shared with team members and caregivers as appropriate. Communication regarding progress, recommendations, and updates is essential for collaborative care.
  10. Ethical and Legal Considerations: Session notes must adhere to ethical guidelines outlined by the Behavior Analyst Certification Board (BACB) and any relevant local, state, and federal regulations.
  11. Training and Orientation: New behavior therapists will receive comprehensive training on the session note standards during their orientation. Training will cover EHR usage, content guidelines, and ethical considerations.
  12. Audit and Quality Assurance: Regular audits will be conducted to ensure compliance with the session note standards. This ongoing quality assurance process will identify areas for improvement and maintain documentation accuracy.
  13. Updates to Standards: These standards will be reviewed annually by the ABA of North Texas management team. Updates will be made to reflect changes in best practices, regulations, or organizational needs.
  14. References and Resources: References to relevant BACB guidelines, ethical codes, and other resources supporting the principles outlined in this document are available to all staff members.
  15. Compliance: Failure to comply with this note-taking policy may result in disciplinary action.
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