rbt E.4 Session Notes

By RBThub February 23, 2026

"If it isn't written down, it didn't happen." This is the golden rule of ABA.

Session notes are legal documents. They are read by your Supervisor, the parents, and insurance companies. If you write "The client was naughty," you look unprofessional. If you write "The client engaged in 5 instances of hitting," you are a scientist.

Executive Summary

This video serves as a "Writing Class for RBTs." It distinguishes between Objective (measurable facts) and Subjective (personal feelings) documentation. It also emphasizes the legal requirements of keeping records secure (HIPAA) and accurate.

⏱️ Video Timeline

09:51
Objective vs. Subjective
Objective = Facts (What you saw). Subjective = Opinions (What you felt). Stick to the facts.
11:08
Effective Communication
"Client screamed and hit table" is effective. "Client was being bad" is ineffective and unprofessional.
12:21
Documentation Methods
Email, secure chats, and session logs. Always ensure the platform is HIPAA compliant.

🔑 Key Insights

The Stranger Test: If a stranger read your note, would they visualize exactly what happened? "Angry" is vague. "Throwing a chair" is specific.
Data + Narrative: Your note should tell the story of the data. If the graph shows 0% compliance, the note should explain why (e.g., illness).
Legal Document: Notes can be subpoenaed in court. Never write anything you wouldn't want a judge to read.
Confidentiality: Never use full names in insecure places. Store physical notes in a locked box.

❓ Frequently Asked Questions

Q: What if I have a "feeling" something is wrong?
A: Report the observable behaviors that gave you that feeling. (e.g., instead of "He seems depressed," write "He kept his head on the desk and refused to speak for 30 minutes").
Q: How long should session notes be?
A: Concise. You don't need a novel. Just cover the goals worked on, behaviors observed, and any significant variables.

1. The Objectivity Slider

Move your language from "Opinion" to "Fact."
SUBJECTIVE "He was mad" "She was lazy" OBJECTIVE "He yelled for 5 mins" "She put head on desk" Goal

2. Anatomy of a Good Session Note

Example Note

Date: 10/24/2023
Location: Home
Staff: John Doe, RBT
Summary: Client engaged in DTT for colors and shapes. Mastery criteria met for "Blue."
Behavior: 2 instances of Tantrum (dropping to floor, screaming) occurred when iPad was removed. Duration: 3 mins each.
Variables: Parent reported client missed lunch.

📝 Knowledge Check

Fix the note.

Q1: Which is the correct way to write: "The client was happy"?

Answer: "The client smiled and laughed while playing with the train."
Describe the behavior (smiling/laughing), not the internal state (happy).

Q2: Why must session notes be "Objective"?

Answer: To ensure accuracy and professionalism.
Objective notes allow anyone reading them to understand exactly what happened without bias.
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Documentation Quiz

Mock Exam

Test your knowledge on Objective Writing and Session Notes.

Start Practice Test

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