Documentation and Reporting

Supervisor

A BCBA or BCaBA responsible for overseeing the RBT's work, data accuracy, and client outcomes.

Supervision Requirement

The BACB requires that 5 percent of an RBT's therapy hours be supervised monthly, with at least two meetings per month.

Effective Communication

Maintaining ongoing, timely, and professional contact with your supervisor about client progress, changes, or incidents.

Examples of Information to Communicate with Supervisor

New or worsening behaviors; skill regression or improvement; medication changes; environmental or family changes; schedule changes; accidents or injuries.

Professional Communication

Always stay respectful, client-focused, and professional; avoid personal or unrelated topics.

Feedback Acceptance

Receive supervisor feedback positively; feedback is meant to help improve your performance and client progress.

Evidence-Based Suggestions

RBTs can suggest ideas supported by ABA principles but must follow the supervisor's final decision.

Clinical Direction

Guidance or clarification from a BCBA or BCaBA about how to run sessions or understand ABA procedures.

Examples of When to Seek Clinical Direction

When a behavior plan is unclear; unexpected behaviors occur; confusion about ABA terms; uncertainty about how to collect data.

Other Variables

Environmental or personal factors that can affect client behavior or therapy outcomes.

Examples of Other Variables to Report

Medication changes; illness or fatigue; sleep issues; family changes; moving homes; emotional events like death or stress; schedule or location changes.

Service Verification

Legal documentation confirming that therapy services were provided as billed.

Objective Session Notes

Factual, measurable records of what occurred during a session; no opinions or assumptions.

SOAP Notes

Standard note format in ABA: Subjective, Objective, Assessment, Plan.

Subjective (SOAP)

Information reported by the caregiver or client; includes observations and changes in environment.

Example of Subjective Note

Parent reports child is more tired since new medication; client was eager to start therapy.

Objective (SOAP)

Observable, measurable data recorded during the session.

Example of Objective Note

Client labeled 80 percent of flashcards correctly; engaged in two tantrums lasting three minutes each.

Assessment (SOAP)

Therapist's analysis of progress or changes since the previous session.

Example of Assessment Note

Client's labeling improved by 10 percent; tantrum duration decreased; client more attentive after sleeping eight hours.

Plan (SOAP)

Future steps in treatment, often "Continue targets as directed by BCBA" unless otherwise updated.

Example of Plan Note

Continue current behavior programs; adjust reinforcement schedule if needed per BCBA guidance.

Confidentiality

The ethical and legal responsibility to protect client privacy and personal information.

HIPAA

Health Insurance Portability and Accountability Act; federal law protecting client data and confidentiality.

Data Retention

Client data must be stored securely for at least seven years, or longer if required by state law.

Secure Data Storage (Paper)

Must be kept in a locked box or cabinet in a locked area; during transport, store in a locked container inside a locked trunk.

Secure Data Storage (Digital)

Data must be password-protected and shared only through encrypted, HIPAA-compliant email or systems.

Data Breach Protocol

If client data is lost, stolen, or leaked, notify your supervisor immediately.

Documentation Compliance

Follow all legal, ethical, and workplace requirements for data storage, transport, and confidentiality.

Example of Objective vs Subjective

Subjective = "Parent says child is cranky." Objective = "Client cried for 3 minutes and threw 2 toys."

Example of HIPAA Violation

Discussing client names in public; sending client data through non-encrypted email; leaving session notes visible in a car.

Example of Data Breach Response

Report to supervisor immediately; describe what was lost or stolen; document event and follow company protocol.