As an RBT, your work doesn’t stop when the session ends. Proper documentation helps tell the story of your client’s progress, challenges, and daily behavior patterns.
In this section, we’ll explore the best practices for session notes, communication, and reporting.
You’ll learn how to objectively record session details, report external variables, and follow workplace reporting policies. Mastery of this unit ensures you’re ready to meet both exam expectations and real-world responsibilities.
E-1: Effectively Communicate with Your Supervisor
Regular communication with your supervisor is a vital part of your job. Whether it’s asking questions, seeking clarification, or reporting something unusual, you should always feel comfortable reaching out.
You are expected to:
- Give regular updates about the learner’s progress and behavior.
- Ask questions when you’re unsure how to implement a procedure.
- Speak up if something in the plan isn’t working as expected.
- Share data and notes in a timely and organized manner.
Communication should always be:
- Clear and specific (e.g., “Today, the client had 4 tantrums lasting 1–2 minutes each.”)
- Professional and respectful
- Based on direct observation and data — not opinions or assumptions
E-2: Actively Seek Clinical Direction When Needed
You may come across a situation that feels new, unexpected, or unclear. As an RBT, you are not allowed to make clinical decisions on your own — that’s your supervisor’s job.
Here are times when you must actively seek direction:
- A behavior appears for the first time or increases in severity
- A parent requests changes to the intervention
- The current strategy doesn’t seem effective
- You’re unsure how to collect data for a target
- You’re asked to implement something not in the behavior plan
It’s your ethical responsibility to recognize these moments and reach out. Document the situation factually and report to your BCBA or designated supervisor immediately.
E-3: Report Other Variables That Might Affect the Client
Clients are affected by more than just what happens in a session.
These outside variables may include:
- Client illness or fatigue
(e.g., “The client appeared tired and yawned frequently during the session.”) - Medication changes
(e.g., “Parent reported starting a new medication yesterday.”) - Family changes or disruptions
(e.g., “Client mentioned a sibling moved out this week.”) - Environmental disruptions
(e.g., “The session was conducted in a different room due to noise.”)
If you observe something or a parent mentions a change, report it to your supervisor. Your job is not to interpret or diagnose — just to communicate what you notice.
Why it matters: These factors may affect how a client behaves or learns, and your supervisor needs that context to make informed decisions.
E-4: Generate Objective Session Notes
Session notes are formal documentation of what happened during your session. They’re used for billing, clinical decisions, and auditing — so they must be clear, accurate, and objective.
Your notes should include:
- Date, time, and duration of session
- What programs were run and how the client responded
- Any problem behavior and how it was handled
- Reinforcers used and how effective they were
- Any relevant changes or observations
Write objectively, using observable terms:
❌ Don’t say: “Client was grumpy.”
✅ Do say: “Client crossed arms, avoided eye contact, and refused to respond to instructions for 10 minutes.”
Avoid opinions, assumptions, and unnecessary emotion. Stick to what you saw, heard, or measured.
E-5: Comply with Legal, Regulatory, and Workplace Requirements
As an RBT, you’re part of a professional field that has strict rules and standards to protect clients, ensure accountability, and uphold the integrity of ABA services. This means following all applicable:
- HIPAA regulations (protecting client privacy)
- BACB® ethical code for RBTs
- State and federal laws relevant to behavior services
- Workplace policies on safety, documentation, reporting, and conduct
This includes:
- Confidentiality: Never share client info with unauthorized individuals — not even friends or family. Don’t post client-related content on social media.
- Accurate timekeeping: Only log hours actually worked. No “guessing” or falsifying data.
- Incident reporting: If something goes wrong or puts the client at risk, report it immediately — even if you feel it was a mistake.
- Scope of practice: You only do what you’re trained and allowed to do. Never design interventions or interpret assessments.
If you’re unsure whether something is allowed, ask your supervisor before acting.