0% found this document useful (0 votes)
6 views2 pages

Session Note Standard

The document outlines the standards for session notes to ensure compliance with audit requirements, including specific sentence counts for session content, legibility of signatures, and inclusion of relevant credentials. It emphasizes the necessity of documenting interventions, goals, and progress trends while adhering to best practices for note-taking and data collection. Failure to meet these standards may result in corrective actions or termination, highlighting the importance of thorough and timely documentation.

Uploaded by

alexa
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
6 views2 pages

Session Note Standard

The document outlines the standards for session notes to ensure compliance with audit requirements, including specific sentence counts for session content, legibility of signatures, and inclusion of relevant credentials. It emphasizes the necessity of documenting interventions, goals, and progress trends while adhering to best practices for note-taking and data collection. Failure to meet these standards may result in corrective actions or termination, highlighting the importance of thorough and timely documentation.

Uploaded by

alexa
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

These are the session note standards needed on all notes in order to

pass an audit:

​ Make the session content paragraphs longer (required 2 sentences per hour). For a 4 hour session you

need 8 sentences. For a 2 hour session you need 4 or more sentences. For a 7 hour session you need

14 sentences.

​ Make signature more legible (sign your full first name and full last name). Clearly written in cursive with

date written under signature.

​ Write session date underneath your signature

​ Add your NPI # (i.e. Alexa Biggs NPI 1215768825, BCBA 1-26-89627, ran a session with ____) .

​ Add your RBT #, BCAT#, BCaBA #, BCBA #, etc. (credential/ license #)

​ Add activities worked on this session to target skills goals and materials used this session during running

trials.

​ List out all interventions used this session in sentence form. For example, to target making poor choices

I used DRA, to target throwing objects I taught a replacement behavior: throw the ball instead of

throwing crayons. To target the tantrum I used calming strategies, taking deep breaths to deescalate the

tantrum. To target elopement we practiced taking a walk and staying with me within arms reach.

​ Add specific goals targeted this session (i.e. intraverbals and tacting)

​ Best practice: type the session note in a Google doc or similar program first. Then cut

and paste the paragraph into aba desk after you run it through a spelling and grammar

check. Fix grammatical errors/ run it through grammarly &/or spell check before pasting it into the session

content paragraph box.

​ List progress towards goals and trends. Ascending, descending, variable, stable trend.

Example,(i.e. Today he performed at 80% with his listener responding: prepositions goal,
ascending trend, on track to master soon by the end of the week.) Another example, today he had only 3

tantrums which is a decrease from yesterday in which he had 5,

descending trends. You don’t have to discuss every target but a top 2, bottom 2 of the

day would be sufficient.

​ Not enough skill acquisition goals ran this session (ie. Should run 4 goals per hour each

session).

​ All targets should be worked on every session. Do not skip running goals. Do not pick

and choose which goals you want to work on and which ones you want to skip. All goals

should be attempted daily. Data should be collected at a rate of 1 set of 10 trials per

every 15 minutes of the session. For example, if a client attended 7 hours and you only ran 2 goals we have

a problem. You should be able to realistically sit at the table for DTT &/or work on targets using NET and

get through 4 targets an hour if not more. Some people can get on a roll and get through 6 targets in an

hour. If a client is here for 7 hours realistically you should be able to record data for 28 goals that

session. A huge red flag when we see clients not even averaging 1 set of trials per hour. If a goal is not

worked on in a session then you absolutely need to begin on that target the following day. Do not go

more than 1 day without running a goal.

​ Not enough skill acquisition goals worked on this session. For instance, (4 sets of 10

trials per 15 minutes of service).

​ Data and session notes are to be submitted daily before you leave the building for the

day. Do not try to save it for home or later. Record data as close to real time as possible.

This is an ethics code, RBT task list and insurance requirement. Consequences will

include: employee corrective actions including remediation and termination. You are well

paid to do your job with us here. Please do not take advantage of us.

Thank you for your effort to make your session notes and data collection to industry standards!

You might also like