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Session Note Update Peer

The memo outlines documentation standards for writing session notes, emphasizing the use of 'peer' instead of other clients' names to maintain confidentiality. This applies to all session notes and aligns with BACB Ethics Code and HIPAA Privacy Rule. Non-compliance may lead to issues during audits.

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2 views1 page

Session Note Update Peer

The memo outlines documentation standards for writing session notes, emphasizing the use of 'peer' instead of other clients' names to maintain confidentiality. This applies to all session notes and aligns with BACB Ethics Code and HIPAA Privacy Rule. Non-compliance may lead to issues during audits.

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

RNH Memo – Documentation Language & Confidentiality Reminder

Please review the following documentation standard with all staff:

When writing session notes, it is appropriate to include the client’s name in place of the word
“client.”

However, when referencing other children involved in the session (group or individual
overlap), staff must use the terms “peer” or “peers” instead of listing or including any other
client names.

This applies to all session notes, including both individual and group services. The purpose is
to ensure all documentation remains confidential and compliant.

Examples:

●​ ✅ Correct:​
“John engaged in parallel play with peers and responded to peer initiations during group

❌
activities.”
●​ Incorrect:​
“John played with Sarah and Michael and responded to Sarah when she asked to share
toys.”

This expectation aligns with:

●​ BACB Ethics Code (Confidentiality – Section 2.06 / 3.01 as applicable), requiring


protection of all client information
●​ HIPAA Privacy Rule, which prohibits unnecessary disclosure of protected health
information (PHI)

Failure to follow this standard may result in compliance concerns during audits.

Thank you for maintaining professional, ethical, and compliant documentation practices.

-Abby

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