Session Notes

Summary: Your session note is the official record that the session happened and that the work was billable. This page covers what belongs in an objective note (data, the procedures you ran, how the client responded), what to leave out (opinions and vague language), the difference between objective and subjective wording, and how solid notes protect you, your supervisor, and the client during clinical review and insurance audits.

Here's the truth nobody tells you on day one: your session note is the only proof the session ever happened. The BCBA wasn't in the room. The insurance company definitely wasn't. Six months from now, when someone reviews this case, your note is the entire record. If it's vague, the work might as well not exist. If it's sloppy, it can get a claim denied or, in a bad year, get you and your supervisor audited.

So treat the note as part of the job, not a chore at the end of it. A good RBT writes a note a stranger could read and understand exactly what you did, how the client responded, and why it mattered. That's the bar. Let's get you there.

What the note is actually for

People throw around "documentation" like it's one thing. It's really doing three jobs at once, and knowing which job you're serving changes how you write.

Clinical. The note is data for the BCBA. It tracks whether the client is acquiring skills, whether behaviors are dropping, and whether the program is being run the way it was designed. When your BCBA decides to fade a prompt or change a reinforcement schedule, they're making that call partly off your notes.