Documentation and Reporting: Section E of the RBT task list pertains to documentation and reporting, which are covered on this page of the study guide for the RBT test. This is a ten-question test covering a fundamental area of applied behaviour analysis.
Because ABA is based on empirical evidence, documentation and reporting play a vital role in the field. Without them, it would be impossible to monitor development, assess the efficacy of therapies, and guarantee that patients get consistent care. In order to enhance the results of treatment, an RBT must keep detailed records and submit them to their supervisor.
Effectively Communicate With a Supervisor in an Ongoing Manner
Regular and consistent communication with your supervisor is essential for a Registered Behaviour Technician. Supervision by a BCBA or BCaBA is required for a minimum of 5% of your direct hours.
If you put in 20 hours per week, for instance, your BCBA is required to supervise for at least 4 hours per month.
Outside of treatment, you should talk to your supervisor about the difficulties. The progress may be improved by having your supervisor listen and making adjustments to the intervention plans. Show receptivity to your supervisor’s comments and suggestions.
In addition, an RBT’s communication style should always be polite and businesslike. Asking your boss to demonstrate something is a perfectly acceptable response if they don’t provide you clear instructions.
Actively Seek Clinical Direction From a Supervisor in a Timely Manner
You should promptly seek counsel from your supervisor, who has greater expertise. Hold off on executing a behaviour intervention plan until you hear from your supervisor if you need clarification. Applying the incorrect strategy to an undertaking may often have the opposite effect of what was intended.
Innumerable situations will arise when you will benefit from the advice of your supervisor. In the following situations, consulting your supervisor is a good idea:
- A previously unseen (and difficult) behaviour emerges from your client: You should make note of any new problematic behaviour that the client exhibits while executing the intervention plan in your session notes and notify your supervisor immediately after the treatment session if the behaviour is damaging or hazardous. Document any new behaviours that raise concerns but aren’t immediately hazardous or destructive. Save a discussion about these concerns until your next appointment with your BCBA.
- There was a marked improvement in your client’s difficult behaviour: Notify your supervisor if your client’s difficult behaviour has worsened significantly after a few treatment sessions. The gravity of the action dictates the time of its disclosure.
- You have no idea what to do while implementing a strategy for goals or behaviour change: Before the next session, you must inform your supervisor if you are unsure about how to execute a behaviour intervention plan for your client.
- Stimuli, data sheets, or anything else you could need: If you need any resources for your sessions, such as data sheets, stimuli, or anything else, it is crucial that you communicate this to your supervisor in advance. It is recommended to inform your supervisor in advance if you think essential products may run out so that they can be restocked promptly.
- It is essential to speak with your supervisor when you face obstacles that are inhibiting progress in treatment. These obstacles may be external, such as a client’s brother, and they are affecting sessions. Setting limits, changing the treatment environment, or incorporating other stakeholders are all ways your supervisor may help you resolve the matter.
Report Other Variables That Might Affect the Client in a Timely Manner
If there are any additional factors influencing your client’s development, you need to inform your supervisor. How to manage such a circumstance will be outlined for you by a BCBA.
Here are some external variables that you should inform your supervisor of:
- Your customer is having trouble falling or staying asleep.
- You have a sick customer.
- Something has happened, or is about to change, in your client’s home (for example, the parents are divorcing, a relative is moving in or out, or the family is relocating).
- A new medicine or a change to an existing one is being started by your client.
- Your client is beginning or ending treatment with several modalities.
- The caretaker for your client came to you with any enquiries or worries.
- Never delay in informing your supervisor and any relevant authorities (such as CPS or DCS) of any suspicions of abuse or neglect.
The urgency of the problem will determine the time frame in which you are required to report to your supervisor. In the event that your client’s illness or fever interrupts treatment sessions, for instance, you must notify your BCBA without delay. However, you may want to hold off until your next supervisorial meeting if your client is scheduled to begin occupational therapy next month.
Follow all relevant legal, regulatory, and workplace guidelines while documenting session activities in order to provide objective session notes for use in service verification.
Each client’s session notes are written by a registered behaviour technician every day. This session is a review of the one before it. The following details are included in the format of the session notes:
- Credentials and your name
- When will the meeting be held?
- Your desired actions and abilities
- A client’s reaction to therapy
- Potential session roadblocks
- Session data (such as behavioural data or program ratings)
Relevant information shared by the parents or caregivers
Your organization’s policies and local legislation will determine the format of your session notes. In terms of note format, you need to adhere to your company’s standards. When you should finish taking notes during a session could vary from one company to the next.
Your session notes should be completed immediately after the therapy session since, as we all know, memories tend to fade with time. It is standard practice for most companies to finish taking notes during meetings within two days.
The client’s medical history is included in the session notes, so please keep it in mind. Because it will be reviewed on a regular basis by your supervisor, team RBTs, parents, and carers, you should write it in an impartial and professional manner.
In your session notes, be sure to only include the quantifiable and observable facts. Keep objective language out of it, such as “client was pleased” or “client didn’t want to work today” unless the customer specifically said otherwise.
Ensure Data Collection, Storage, Transportation, and Documentation Adheres to All Necessary Legal, Regulatory, and Workplace Objectives
Ensuring the security of customer data is paramount. You have a responsibility to your clients as RBTs to adhere to all regulations regarding the handling of their personal information. In the United States, this entails adhering to local and national statutes, such as the Health Insurance Portability and Accountability Act (HIPAAs).
The confidentiality and security of your customers’ personal information is guaranteed by these regulations. By strictly adhering to these guidelines, we are able to safeguard our customers’ personal information, keep their confidence, and prevent issues related to unauthorised access.
These days, it’s common practice for businesses to employ data collection and session note writing solutions that are HIPAA compliant. Compared to paper papers, these digital solutions greatly reduce the possibility of unintentional disclosure or loss of sensitive customer information.
Better privacy protection and data security for your clients is possible with the help of these technologies.
