Documentation, Reporting & Professional Conduct

Wednesday

Why is documentation important?

Documentation provides an accurate record of services, client progress, and important events to help guide treatment decisions.

What should documentation include?

Objective, accurate, and timely information about the client’s behavior and the services provided.

What does “objective” mean?

Record only observable facts—not opinions, assumptions, or feelings. Example “The client cried for 3 minutes.” Not “The client was upset because they were spoiled.”

When should session notes be completed?

As soon as possible after the session, following your organization’s procedures.

Should you ever make up data if you forgot to record it?

No. Only document what actually occurred.

What should you do if you accidentally make an error in documentation?

Correct it according to your organization’s procedures and notify your supervisor if required.

What types of changes should be reported to your BCBA?

New challenging behaviors, changes in behavior patterns, safety concerns, illness or injury affecting services, and significant environmental changes that may impact treatment.

Should an RBT report concerns immediately?

Yes, especially if client safety or treatment effectiveness may be affected.

What should you do if a parent tells you they changed the client’s medication?

Document the information and report it to your BCBA according to your organization’s procedures.

Should an RBT give medical advice?

No. Refer medical questions to the appropriate healthcare provider.

How should an RBT communicate with families?

Professionally, respectfully, and within the limits of their role.

Can an RBT promise specific treatment outcomes?

No. No one can guarantee results.

What if a family asks you to change a program?

Thank them for sharing and let them know you’ll communicate their concerns to the BCBA.

Can an RBT discuss another client’s progress?

No. This violates confidentiality.

Who should receive confidential client information?

Only authorized individuals.

Why is supervision important?

It helps ensure services are ethical, effective, and implemented correctly.

Should an RBT ask questions during supervision?

Yes. Supervision is the time to seek clarification, feedback, and guidance.

Should an RBT accept feedback?

Yes. Feedback is an important part of professional growth.

What should you do if you don’t understand a new procedure?

Ask your BCBA before implementing it.

What does professionalism include?

Honesty, reliability, respect, appropriate communication, and ethical behavior.

Why is punctuality important?

It supports continuity of care and demonstrates professionalism.

Should you arrive prepared for sessions?

Yes. Review programs, gather materials, and be ready to work.

What should you do if you’re running late?

Follow your organization’s procedures and notify the appropriate people as soon as possible.

Can personal problems interfere with client care?

Professional behavior means managing personal issues appropriately and seeking support when needed so client care is not compromised.

What should you do if you feel overwhelmed or unsure?

Ask your BCBA or supervisor for support and guidance.

Should you continue learning after becoming an RBT?

Yes. Professional development is an ongoing responsibility.

Why should RBTs stay within their competence?

To protect clients and provide high-quality services.

Can an RBT independently change treatment goals?

No. Only the BCBA can make treatment changes.

What if you observe something concerning during a session?

Document it objectively and report it according to your organization’s procedures.

What is the most important professional rule?

Be honest, follow the treatment plan, collect accurate data, protect confidentiality, and ask your BCBA whenever you’re unsure