RBT SESSION NOTE COMPLIANCE
CHECKLIST
(For RBTs & Student Analysts)
✅ All items must be completed unless marked “if applicable.”
❌ Missing or vague items are a common reason for insurance denials.
1. BASIC SESSION INFORMATION (REQUIRED)
☐ Client full name
☐ Client DOB or ID number
☐ Date of service
☐ Start time and end time (no overlaps, matches billing)
☐ Total session duration
☐ Location of service (home, clinic, school, telehealth, etc.)
☐ RBT name and credential
☐ Supervising BCBA name
2. SERVICE TYPE & AUTHORIZATION ALIGNMENT
☐ Correct service type documented (e.g., Direct ABA / Adaptive Behavior Treatment)
☐ Session occurred within authorized hours
☐ Session aligns with the current treatment plan
☐ No services outside RBT scope of practice documented
🚫 Do NOT include:
● Clinical decision-making
● Program changes
● New goals
● Diagnostic language
3. TREATMENT GOALS & PROGRAM IMPLEMENTATION
☐ Specific goals/programs addressed are listed
☐ Goals are written exactly as they appear in the treatment plan
☐ Each goal addressed includes:
● ☐ Teaching procedure used (e.g., DTT, NET, prompting)
● ☐ Materials or context (natural environment, structured task, etc.)
🚫 Avoid vague language like:
“Worked on goals,” “Did ABA,” “Targeted behaviors”
4. DATA COLLECTION (CRITICAL)
☐ Data collected for every goal addressed
☐ Data type clearly stated (frequency, duration, trials, percentage, etc.)
☐ Data is objective and measurable
☐ No estimated or guessed data
☐ Data reflects actual session performance
🚫 Never write:
● “Client did well”
● “Good progress today”
(without data)
5. CLIENT RESPONSE & SKILL ACQUISITION
☐ Client response to intervention is described objectively
☐ Skill performance described using observable behaviors
☐ Progress or lack of progress is supported by data
☐ Any changes in motivation, attention, or engagement noted
✅ Example:
“Client independently requested preferred items in 6/10 opportunities using vocal mands.”
6. MALADAPTIVE BEHAVIOR DOCUMENTATION (IF
APPLICABLE)
If maladaptive behavior occurred:
☐ Behavior name matches treatment plan
☐ Objective description provided (what it looked like)
☐ Antecedent identified
☐ Consequence described
☐ Frequency/duration recorded
☐ Intervention used matches the BIP
☐ Client response to intervention documented
🚫 Do NOT include opinions or emotional language
(“angry,” “defiant,” “manipulative”)
7. PROMPTING & REINFORCEMENT
☐ Prompt levels used are documented
☐ Prompt fading noted when applicable
☐ Reinforcers used are identified
☐ Reinforcement aligns with the treatment plan
8. SESSION VARIABLES & BARRIERS
☐ Any factors impacting session noted:
● ☐ Illness
● ☐ Fatigue
● ☐ Schedule changes
● ☐ Environment disruptions
● ☐ Staffing issues
☐ Barriers are documented objectively
☐ No blame or judgment language used
9. GENERALIZATION & MAINTENANCE (IF ADDRESSED)
☐ Generalization attempts documented (new setting, person, materials)
☐ Maintenance trials noted if applicable
☐ Client performance clearly stated
10. CAREGIVER INVOLVEMENT (IF APPLICABLE)
☐ Caregiver presence noted
☐ Caregiver activities described (observed, assisted, trained)
☐ No parent training documented unless BCBA-directed
🚫 RBTs should NOT document:
● Teaching parents independently
● Providing clinical guidance
11. ETHICS, SAFETY & INCIDENTS (IF APPLICABLE)
☐ Any safety concerns documented objectively
☐ Any injuries documented per policy
☐ Any protocol deviations explained
☐ No mention of internal policy disputes
12. CLINICAL LANGUAGE & PROFESSIONALISM
☐ Language is objective and factual
☐ No opinions, emotions, or assumptions
☐ No slang or casual language
☐ No diagnostic or evaluative conclusions
🚫 Avoid phrases like:
● “Client was stubborn”
● “Client didn’t want to”
● “Client had a bad attitude”
13. SUMMARY STATEMENT (REQUIRED)
☐ Brief, objective session summary included
☐ Summary reflects:
● What was worked on
● How the client responded
● Any significant barriers or successes
✅ Example:
“Client participated in NET targeting functional communication and compliance goals. Data
indicated increased independent responding compared to prior session. No safety concerns
noted.”
14. FINAL REVIEW BEFORE SUBMISSION
☐ Note is completed same day as service
☐ Spelling and grammar checked
☐ Matches billed time exactly
☐ Supervisor can clearly understand the session
☐ Note would make sense to an insurance auditor
SUPERVISOR TIP (OPTIONAL ADD-ON)
Have student analysts answer this yes/no question before submission:
“If an insurance auditor read this note with no additional explanation, would they
understand exactly what services were provided and why they were medically
necessary?”
☐ Yes ☐ No (revise if “No”)