6 Documentation and Reporting Free Online FlashCards

What qualities make a session note useful?

A useful session note is factual, specific, timely, and understandable to another authorized team member.

How should an RBT describe a client's behavior in a note?

Describe observable actions rather than guessing at thoughts, motives, or feelings.

How should a note handle another person's interpretation?

Identify who made the statement or interpretation instead of presenting it as your own observation.

What is the rule for recording session data?

Record data as collected; do not estimate missing measurements or alter results to make progress appear better.

How should an RBT correct a documentation error?

Use the organization's approved correction method so both the original entry and correction remain clear.

What should you do when records conflict or information is missing?

Do not guess or silently change entries; promptly ask the supervisor how to resolve the discrepancy.

What services should documentation reflect?

Documentation must reflect services actually provided, not services that were planned, missed, or shortened.

What should an RBT do about a change that may affect service?

Tell the supervisor promptly. Report what was observed, when it happened, and what action was taken.

What should an RBT do with clinical questions about a plan?

Do not independently diagnose, change goals, or modify behavior procedures; refer clinical questions to the supervisor.

What comes first when an injury or safety concern occurs?

First take steps needed to protect the client, then follow emergency and organizational procedures.

What facts belong in an incident report?

Record facts such as the time, location, people present, observable events, immediate response, and notifications—without speculation or blame.

Does notifying a supervisor always satisfy mandated reporting?

No. Telling a supervisor does not necessarily replace a report required by law; follow applicable mandated-reporting requirements.