RBT Documentation Guide: Notes & Progress Reports

Accurate documentation and reporting are essential responsibilities of an RBT. These records serve multiple purposes: tracking client progress, communicating with team members, meeting legal and ethical requirements, and supporting insurance reimbursement. This section covers session notes, problem behavior documentation, and graph preparation.

E-1: Report Other Variables That Might Affect the Client

Environmental Variables

Physical Environment Factors:

• Changes to treatment setting (new location, rearrangement)
• Noise level variations (construction, alarms, other clients)
• Lighting changes (power outages, sensory accommodations)
• Temperature issues (heating/cooling problems, extreme weather)
• Space limitations or changes (room changes, shared spaces)
• New equipment or materials in environment
• Presence of distractions or novel stimuli

Example Documentation: “Session conducted in cafeteria instead of therapy room due to school testing. Environment had increased noise level, frequent transitions of other students, and limited table space for materials.”

Scheduling and Timing Variables:

• Session duration changes (shortened/extended sessions)
• Time of day variations from typical schedule
• Sequence changes in regular routine
• Unexpected interruptions or transitions
• Delays in session start or premature endings
• Canceled or missed prior sessions
• School/work schedule changes affecting client

Example Documentation: “Session shortened to 30 minutes (vs. typical 60 minutes) due to client doctor appointment. Session conducted at 9:00 AM rather than usual 1:00 PM time slot.”

Staffing Variables:

• Change in primary therapist or instructor
• New or substitute staff working with client
• Changes in supervision level or structure
• Multiple therapists present (training, transition)
• Absence of regular team members
• Change in staff-to-client ratio
• New observers or evaluators present

Example Documentation: “Regular therapist on vacation; session conducted by Ms. Johnson (substitute). BCBA supervisor present for first 30 minutes for transition support.”

Client Variables

Physical State Factors:

• Illness or signs of physical discomfort
• Medication changes (new medications, dosage changes, missed doses)
• Fatigue or sleep disturbances reported by caregivers
• Hunger or thirst (missed meals, feeding schedule changes)
• Injuries or pain (reported or observed)
• Seizure activity or other medical events
• Changes in physical appearance (weight, hygiene)

Example Documentation: “Client’s mother reported client only slept 4 hours last night due to ear pain. Client seen rubbing right ear throughout session and yawning frequently. Scheduled break frequency increased to accommodate fatigue.”

Emotional State Factors:

• Observed mood changes from baseline
• Emotional reactions to events outside session
• Anxiety or stress indicators
• Significant emotional events (celebrations, losses)
• Family stressors reported by caregivers
• Changes in affect or emotional regulation
• Motivation level variations

Example Documentation: “Client entered session crying and stated ‘I miss my dad.’ Mother reported father deployed overseas yesterday. Client showed reduced verbal interaction for first 20 minutes of session but responded to preferred activities after brief calming period.”

Routine Disruption Factors:

• School/work schedule changes
• Family routine changes (moves, vacations, visits)
• Transportation issues affecting arrival/departure
• Holiday or special event disruptions
• Weather-related disruptions
• Family structural changes (new sibling, visitor)
• Significant life transitions (school changes, moves)

Example Documentation: “Family relocated to new home this weekend. Client in new bedroom environment and reported difficulty sleeping. Parents note establishment of new morning routine is in progress.”

Implementation Integrity Variables

Procedural Consistency Factors:

• Deviations from written protocols
• Errors in implementation procedures
• Modifications made during session
• Novel strategies attempted
• Reinforcement schedule changes
• Prompt level adjustments
• Materials or activity substitutions

Example Documentation: “Token economy modified during session due to client’s decreased response to established reinforcers. Tokens exchangeable every 5 minutes versus typical end-of-session exchange.”

Resource Limitation Factors:

• Missing or unavailable materials
• Technology failures affecting programs
• Unavailability of planned reinforcers
• Space limitations impacting implementation
• Time constraints affecting protocol completion
• Staffing shortages impacting support
• Access limitations to necessary environments

Example Documentation: “iPad application for communication training unavailable due to technical error. Substitute picture communication cards used for requesting activities, resulting in decreased independence compared to previous sessions.”

Documentation Best Practices

Objective Language Requirements:

• Use observable, measurable terms
• Avoid subjective interpretations
• Include specific examples
• Quantify observations when possible
• Distinguish facts from opinions/hypotheses
• Use neutral, professional terminology
• Provide context for observations

Comparison of Subjective vs. Objective Statements:

Documentation Relevance:

• Focus on variables with potential behavior impact
• Include factors relevant to program implementation
• Document variables affecting data interpretation
• Report changes from established baseline conditions
• Note factors requiring potential protocol modifications
• Include information needed for team communication
• Document occurrences relevant to client goals

Example Documentation Decision Process: When determining whether to document client’s new shoes:

• If client showed no unusual behavior and shoes created no implementation issues → Not relevant to document
• If client was repeatedly distracted by shoes, affecting attention to tasks → Relevant to document
• If shoes caused physical discomfort affecting session participation → Relevant to document
• If new shoes were reinforcers being incorporated into program → Relevant to document

E-2: Generate Objective Session Notes by Describing Observed Behavior

Session Note Components

Essential Documentation Elements:

1. Client Identifier: Name/ID (following confidentiality protocols)
2. Date and Time: Session date, start/end times, duration
3. Setting: Location, environmental conditions
4. Present Individuals: Staff, caregivers, others present
5. Goals/Targets Addressed: Skills/behaviors targeted
6. Procedures Implemented: Specific interventions used
7. Client Response Data: Quantitative performance measures
8. Progress Summary: Comparison to previous performance
9. Significant Events: Unusual occurrences, changes, incidents
10. Plan Modifications: Any protocol adjustments made
11. Next Steps: Focus for upcoming sessions
12. Signature: Provider credentials and signature

Example Comprehensive Session Note:

Client: J.D.            Date: 4/15/2023    Time: 9:00-11:00 AM
Setting: Client's home - living room
Present: RBT (self), mother (first 30 min), father (last 45 min)

Goals Addressed:
1. Manding using 2-word phrases
2. Independent toothbrushing
3. Waiting with visual timer (2-minute duration)

Procedures Implemented:
- Natural Environment Teaching for manding
- Backward chaining for toothbrushing
- Visual timer with token reinforcement for waiting

Client Response:
1. Manding: 15 opportunities, 9 independent 2-word phrases (60%), 4 with verbal prompt (27%), 2 with model prompt (13%). Increase from 45% independent last session.
2. Toothbrushing: Completed steps 7-10 of task analysis independently (40%), required partial physical prompts for steps 1-6. Consistent with previous session.
3. Waiting: Tolerated 2-minute wait for 5/6 trials (83%) with visual timer. One instance of verbal protest without aggression. Improvement from 67% last session.

Significant Events: New toothbrush introduced today (character preference). Client initially resistant but became accepting after demonstration.

Modifications: Increased waiting interval from 90 seconds to 2 minutes based on previous mastery.

Next Steps: Continue increasing independent toothbrushing focusing on steps 5-6. Maintain 2-minute waiting interval. Begin introducing novel listeners for manding generalization.

RBT Signature: ________________ Date: 4/15/2023

Progress Reporting Elements:

• Comparison to previous session performance
• Progress toward mastery criteria
• Trend descriptions (improving, maintaining, regressing)
• Rate of skill acquisition observations
• Generalization across settings/people/materials
• Maintenance of previously mastered skills
• Barriers to progress identified

Example Progress Statement: “Client demonstrated 80% independent responding on sorting task, maintaining performance level from previous two sessions but not yet meeting 90% mastery criterion. Generalization probe with novel materials showed 60% accuracy, indicating need for additional exemplar training.”

Objective Behavior Description

Defining Characteristics of Objective Description:

• Observable and measurable terms
• Specific behavioral topography
• Quantifiable dimensions (frequency, duration, intensity)
• Contextual factors and conditions
• Free from interpretation or inference
• Replicable by independent observer
• Precise operational language

Components of Thorough Behavior Description:

1. Topography: What the behavior looked like
2. Frequency: How often behavior occurred
3. Duration: How long behavior lasted
4. Intensity: Magnitude or force of behavior
5. Antecedents: What happened before behavior
6. Consequences: What happened after behavior
7. Setting: Where and when behavior occurred
8. Pattern: How behavior changed during session

Comparing Subjective vs. Objective Descriptions:

Example Objective Behavior Incident Description: “At 10:15 AM during independent work, when presented with 4-digit subtraction problems, client pushed worksheet away (approximately 6 inches), stated ‘This is stupid,’ and put head down on desk for 45 seconds. RBT implemented protocol by restating expectation once, providing 2-minute break option with break card, and setting visual timer. Client used break card independently, took 2-minute break with timer, then returned to complete 3 of 5 problems with verbal praise for task re-engagement.”

Standardized Note Formats

SOAP Notes Structure:

• Subjective: Information reported by client/others
• Objective: Observable data and direct measurements
• Assessment: Analysis of current status and progress
• Plan: Next steps and recommendations

Example SOAP Note:

Subjective: Client's mother reported client slept poorly last night and missed morning medication dose.

Objective: Client required an average of 3.5 verbal prompts per task initiation compared to typical 1.2 prompts. Self-stimulatory behavior observed during 65% of session (10-second momentary time sampling) compared to average of 32% over previous 5 sessions. Task completion rate of 4 mastered tasks was 75% (3/4 tasks).

Assessment: Increased prompt dependency and self-stimulatory behavior likely influenced by reported sleep disruption and missed medication. Despite these factors, client maintained relatively high task completion rate on mastered tasks. No progress made on acquisition targets.

Plan: Continue current acquisition programs next session. If sleep/medication issues continue, consider temporarily reducing task demands and increasing reinforcement schedule. Follow up with caregiver regarding medication consistency.

DAP Notes Structure:

• Data: Observable information and measurements
• Assessment: Interpretation and analysis of data
• Plan: Future direction and intervention adjustments

Example DAP Note:

Data: Client completed 4-step toileting routine with physical prompts for steps 1-2 and gestural prompts for steps 3-4. Total of 3 toileting opportunities during 2-hour session. No toileting accidents occurred. Client indicated need to use bathroom by approaching bathroom door once and pointing to toilet picture on communication board twice.

Assessment: Client showing emerging request behavior for toileting needs, a new skill development. Prompt dependency for initial steps of routine remains consistent with previous sessions. Successful accident prevention maintained from previous 3 sessions.

Plan: Begin graduated guidance fading for step 2 (pulling down pants) during next session. Continue reinforcing all communication attempts for toileting. Maintain visual task analysis in bathroom.

ABC Notes Structure:

• Antecedent: Events preceding target behavior
• Behavior: Objective description of response
• Consequence: Events following target behavior

Example ABC Note:

Antecedent: Transition signal provided for ending preferred computer activity. Visual timer showed 2 minutes remaining. Verbal reminder given: "Two minutes until math work."

Behavior: Client vocalized "No math" in raised voice (approximately 2x conversation volume). Client pressed computer power button to shut down before timer completed. Client moved to corner of room away from work area.

Consequence: RBT provided calm verbal reminder of schedule, presented visual schedule showing computer then math then break. After 45 seconds in corner, client returned to table, computer privilege withheld per behavior plan, math activity presented with first problem completed as model.

E-3: Generate Objective Short-Term Goals and Effectively Communicate Progress

Components of Measurable Goals

SMART Goal Framework:

• Specific: Clearly defined target behavior
• Measurable: Quantifiable performance criteria
• Achievable: Realistic given client abilities
• Relevant: Meaningful for client’s needs
• Time-bound: Specified timeframe for achievement

Essential Goal Components:

1. Target Behavior: Specific skill to be acquired
2. Conditions: Situation in which behavior occurs
3. Criterion: Performance level required for mastery
4. Timeframe: Expected period for goal achievement
5. Measurement System: How progress will be evaluated

Example Well-Written Goals:

“By June 30 (timeframe), during structured play activities (condition), Client will request preferred items using 2-word phrases (target behavior) in 80% of opportunities across 3 consecutive sessions (criterion) as measured by frequency data (measurement).”

“Within 6 weeks (timeframe), during community outings (condition), Client will wait appropriately while standing in line (target behavior) for durations of 5 minutes on 4/5 opportunities (criterion) as measured by duration recording (measurement).”

“By the end of the quarter (timeframe), when presented with independent academic work (condition), Client will self-monitor on-task behavior using a visual checklist (target behavior) with 90% accuracy compared to therapist monitoring (criterion) as measured by permanent product recording (measurement).”

Common Goal-Writing Errors:

Progress Reporting

Data-Based Progress Statements:

• Reference specific, measurable performance data
• Compare current performance to baseline or previous periods
• Include rate of progress information
• Identify trend direction (increasing, stable, decreasing)
• Note variability or consistency in performance
• Connect data to established criteria
• Document conditions affecting performance

Example Progress Statements:

“Client currently identifies 8/10 targeted community safety signs independently (80%), an increase from 3/10 (30%) at baseline assessment 4 weeks ago. This represents progress toward 90% criterion, with steady improvement of approximately 12.5% per week.”

“Client’s on-task behavior during 20-minute independent work periods has increased from mean duration of 5 minutes at baseline to current mean of 12 minutes, representing 60% of session time. Progress has plateaued over past 2 weeks, remaining between 11-13 minutes per session.”

Barriers to Progress Documentation:

• Identify specific factors impeding expected progress
• Document intervention modifications attempted
• Note pattern of response to modification attempts
• Specify additional assessment needs
• Recommend potential alternative approaches
• Link observations to data patterns
• Indicate consultation needs or resources required

Example Barriers Documentation:

“Client’s progress on independent toothbrushing has plateaued at 50% independence (steps 6-10 of task analysis) for 3 weeks despite systematic prompt fading. When physical prompts are faded for steps 1-5, accuracy drops below 20%. Attempted modifications include changing toothbrush type, introducing video modeling, and altering reinforcement schedule, all with minimal impact. Recommend reassessment of fine motor skills and consultation with occupational therapist regarding potential sensory barriers.”

“Client shows inconsistent progress on expressive labeling program. Performance ranges from 30-90% accuracy within same session and across days. Possible barriers include fluctuating motivation, inconsistent implementation across therapists, and potential overestimation of receptive understanding. Modifications attempted include increased reinforcement quality, therapist standardization training, and additional receptive identification practice. Recommend formal reassessment of prerequisite skills and adjustment of target complexity.”

Communicating with Stakeholders

Tailoring Communication to Audience:

• Parents/Caregivers: Emphasize functional progress, everyday implications
• Teachers: Focus on classroom-relevant skills, academic connections
• Other Professionals: Use discipline-specific terminology appropriately
• Funding Sources: Highlight objective measures, return on investment
• Client (When Appropriate): Age/ability-appropriate progress feedback

Professional Communication Guidelines:

1. Use clear, concise language
2. Avoid jargon with non-technical audiences
3. Supplement data with functional examples
4. Maintain confidentiality standards
5. Present balanced perspective (strengths and needs)
6. Check for understanding and questions
7. Provide written summaries of key points
8. Maintain respectful, person-first language

Example Stakeholder Communications:

For Parent: “Alex has made significant progress with his communication skills this month. He’s now using his picture card system to request his favorite foods and activities throughout the day, averaging 15 spontaneous requests per 2-hour session compared to just 3-4 requests when we started. This means he’s finding more effective ways to get his needs met without becoming frustrated. At home, you might notice more opportunities to respond to these picture requests, especially around snack time and when choosing activities.”

For Teacher: “Jasmine has developed several skills that should support her classroom participation. She’s now consistently raising her hand for attention rather than calling out, with hand-raising now occurring in 85% of opportunities. She’s also increased her independent work time from 5 minutes to 15 minutes using the visual timer system. We’re using the same visual schedule format that you have in the classroom, and she’s referencing it independently about 50% of the time now.”

For Speech-Language Pathologist: “Marcus has achieved mastery criteria on three receptive preposition targets (in, on, under) in structured DTT format with 90% accuracy across 3 consecutive sessions. He’s showing emerging generalization to novel objects (40-60% accuracy) but continues to demonstrate position confusion in naturalistic settings. We’ve implemented a consistent error correction procedure and are using both 2D and 3D materials in training.”

E-4: Update Graphs

Graph Construction Fundamentals

Essential Graph Components:

1. Title: Clear description of target behavior/skill
2. Data Points: Accurate plotting of individual measurements
3. X-Axis: Time dimension (sessions, days, weeks)
4. Y-Axis: Dependent variable (behavior measure)
5. Phase Change Lines: Vertical lines indicating intervention changes
6. Phase Labels: Brief descriptions of conditions
7. Condition Key/Legend: Explanation of data series
8. Client Identifier: Confidential client ID or initials
9. Date Range: Time period covered by graph
10. Target/Aim Line: Indication of goal criteria (when applicable)

Common Graph Types and Applications:

Line Graphs:

• Most common for tracking behavior change over time
• Shows trend direction, variability, and level
• Effective for continuous data or percentage measures
• Allows visual analysis of intervention effects
• Suitable for most skill acquisition and behavior reduction targets

Bar Graphs:

• Useful for comparing discrete categories
• Effective for displaying assessment results
• Good for comparing performance across settings/people
• Helpful for summarizing period-to-period changes
• Suitable for non-continuous measurement periods

Cumulative Graphs:

• Shows total performance over time
• Clearly displays acceleration/deceleration
• Effective for counting behaviors (total instances)
• Useful for monitoring overall output/productivity
• Suitable for skills with countable discrete responses

Scatterplots:

• Displays relationship between two variables
• Useful for identifying temporal patterns
• Effective for analyzing contextual influences
• Reveals correlations between behaviors or conditions
• Suitable for complex behavior pattern analysis

Data Plotting Procedures

Accurate Data Point Placement:

1. Identify exact measurement value for session
2. Locate corresponding position on y-axis
3. Identify correct session/date on x-axis
4. Place point at intersection of x and y coordinates
5. Verify placement against original data
6. Connect points within same condition (not across phase changes)
7. Use consistent data point symbols throughout

Example Plotting Procedure: For a line graph tracking percentage of independent responses:

• Session 1: 40% independent responses → Plot at intersection of Session 1 (x-axis) and 40% (y-axis)
• Session 2: 45% independent responses → Plot at intersection of Session 2 (x-axis) and 45% (y-axis)
• Connect Session 1 and 2 points with straight line
• Session 3: 42% independent responses → Plot at intersection of Session 3 (x-axis) and 42% (y-axis)
• Connect Session 2 and 3 points with straight line
• Continue process for all sessions within phase

Phase Change Indication:

1. Identify exact session where intervention changed
2. Draw vertical line between that session and next
3. Extend line through full height of graph
4. Avoid connecting data points across phase line
5. Label phases clearly above or within graph
6. Use consistent phase change marking throughout

Example Phase Change Documentation: For intervention change from baseline to intervention:

• Last baseline session: Session 5
• First intervention session: Session 6
• Draw vertical line between Sessions 5 and 6
• Label left side of line “Baseline”
• Label right side of line “Intervention”
• Do not connect data point from Session 5 to Session 6

Scale Considerations:

• Set y-axis range to accommodate all data points
• Include zero on y-axis when possible/appropriate
• Maintain consistent scale throughout monitoring
• Use breaks in axis only when absolutely necessary
• Ensure scale units are easily interpretable
• Match scale precision to measurement precision
• Consider expected range for future data points

Common Scaling Errors:

• Compressed scale obscuring important variations
• Expanded scale exaggerating minor variations
• Inconsistent scaling between related graphs
• Inappropriate scale units for measurement system
• Omitting zero artificially inflating changes
• Scale breaks creating visual distortion
• Overcomplicated increments hindering interpretation

Electronic Graphing Systems

Advantages of Electronic Graphing:

• Automatic calculation of summary statistics
• Perfect geometric precision in representation
• Easy updating with new data points
• Multiple view options for same dataset
• Automatic phase change formatting
• Consistent visual presentation across graphs
• Simple sharing/storage of visual data
• Integration with electronic data collection systems

Common Electronic Graphing Tools:

• Specialized behavior analysis software
• Spreadsheet programs with graphing functions
• Online graphing applications
• Data collection apps with built-in graphing
• Statistical analysis programs
• Practice management systems with data features

Implementation Procedures:

1. Enter raw data into appropriate electronic format
2. Select appropriate graph type for data
3. Specify phase change locations and labels
4. Verify auto-plotted points against raw data
5. Adjust titles, labels, and legends as needed
6. Format appearance for clarity and professionalism
7. Save in appropriate file format for intended use

Quality Control for Electronic Graphing:

• Double-check data entry against original records
• Verify calculation formulas are correct
• Ensure phase changes correctly indicated
• Check scaling for appropriate representation
• Review titles and labels for accuracy
• Confirm proper date/session sequencing
• Test printability and sharing compatibility

Visual Analysis Fundamentals

Level:

• Central tendency or average within phase
• Relative position of data on y-axis
• Often assessed using median or mean
• Important for comparing absolute performance across phases
• Indicates magnitude of behavior occurrence

Trend:

• Direction of data path over time
• Increasing, decreasing, or stable pattern
• Slope indicates rate of change
• Can be assessed visually or via trend line
• Important for predicting future performance

Variability:

• Degree of fluctuation around trend
• Range between highest and lowest points
• Consistency/inconsistency within phase
• Indicates response stability or instability
• May reveal multiple controlling variables

Immediacy of Effect:

• Change between last data points of one phase and first points of next
• Rapid vs. gradual change following intervention
• Magnitude of initial effect
• Temporal relationship to intervention change
• Indicates intervention power/relevance

Overlap:

• Degree of similar values across adjacent phases
• Percentage of data points that could appear in either phase
• Low overlap suggests stronger intervention effect
• High overlap suggests questionable intervention effect
• Quantifiable using percentage of non-overlapping data points

Example Visual Analysis Statement: “Following implementation of the token economy system (Session 6), on-task behavior showed an immediate level increase from baseline mean of 42% to intervention mean of 78%. An increasing trend is evident within the intervention phase (approximately 5% increase per session), with reduced variability compared to baseline (range narrowed from 35% to 15%). Only one intervention data point overlaps with the highest baseline point, indicating a reliable intervention effect.”

Communication With Graphs

Effective Graph Presentation:

• Present simplest effective visual representation
• Highlight key patterns with annotations when needed
• Pair graphs with brief narrative explanation
• Ensure readability from typical viewing distance
• Use color strategically (if available) but not exclusively
• Maintain professional, uncluttered appearance
• Consider audience visual literacy level

Connecting Data to Decisions:

• Explicitly relate visual patterns to intervention decisions
• Identify decision rules for program modifications
• Mark specific data points triggering changes
• Document response to modification on same timeline
• Use graphs to justify continuation or adjustment
• Connect visual data to mastercq criteria and goals
• Review graphs regularly with supervisor

Example Data-Based Decision Documentation: “Based on the stability of performance within the current phase (5 consecutive data points within 5% range) and achievement of defined mastery criterion (90% independence across 3 consecutive sessions), we will discontinue daily data collection on toothbrushing and move to weekly maintenance probes. Graph indicates reliable performance since Session 12, with no prompts required since Session 15.”

Stakeholder Graph Interpretation Support:

• Explain axes and measurement units clearly
• Define technical terms used in graphs
• Point out specific features demonstrating progress
• Connect graph patterns to functional outcomes
• Provide concrete examples of what numbers represent
• Scale complexity to audience understanding
• Check for questions and misinterpretations
• Provide written explanation to accompany graphs

Example Caregiver Graph Explanation: “This graph shows your child’s progress with independent dressing skills over the past month. The bottom line shows the dates we worked together, and the side shows the percentage of steps he completed without help. Each dot represents one session. As you can see, when we started here [point], he needed help with most steps, completing only about 20% independently. After we introduced the visual sequence card here [point to phase change], his independence increased steadily. Now he’s completing about 75% of dressing steps without any help. These last few points show he’s maintaining this skill consistently.”