Documentation and Reporting
E-01 Effectively Communicate with Supervisor
E-02 Actively seek clinical direction from supervisor in a timely manner.
E-03 Report other variables that might affect the client in a timely manner.
E-04 Generate objective session notes for service verification by describing what occurred during the sessions, in accordance with applicable legal, regulatory, and workplace requirements
E-05 Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements
E-01 Effectively Communicate with Supervisor
Effectively communicating with your supervisor is essential for ensuring that the interventions being implemented are appropriate for the client and that progress is being monitored effectively. This includes being able to clearly and effectively convey information about the client’s progress and any concerns that may arise.
E-02 Actively seek clinical direction from supervisor in a timely manner
Actively seeking clinical direction from a supervisor is important for ensuring that interventions are appropriate and that progress is being monitored effectively. This includes being able to ask for and receive guidance and feedback from your supervisor, as well as being able to follow through on any suggestions or recommendations provided.
E-03 Report other variables that might affect the client in a timely manner
An example of ?other variables? that an RBT would need to report to a supervisor would include things like disruptions to a client?s routine, illness, medication changes and sleep difficulties. In effect, these types of event act as setting events. Knowing that they have happened, will enable supervisors to interpret data appropriately.
As an RBT, you need to be able to identify and report any relevant changes in the client’s environment or behavior that might be impacting progress, as well as being able to make appropriate adjustments to interventions as needed with the guidance of your supervisor.
E-04 Generate objective session notes for service verification by describing what occurred during the sessions, in accordance with applicable legal, regulatory, and workplace requirements
As an RBT, you should complete your session notes with objectivity. This means that your sessions notes should only discuss facts in a professional manner. You will note various settings events or other factors that may have affected a client?s behavior during the session, describe the interventions that were implemented and report the client?s success rates with regard to skills teaching . It is important that you use objective language (e.g. ?Tom had 8 instances of kicking today? rather ?Tom was angry today ? lots of kicking?). You should avoid unnecessarily interpreting a client?s behaviour or be specific.
E-05 Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements
An RBT should ensure their familiarity with the Data Protection laws and regulations that exist within the jurisdiction in which they operate. It is essential that an RBT complies with these laws and regulations. You should store client data sheets, session notes, and paperwork in a secure location. You should always put them back after a session so that they are kept in that safe location. If you provide home-based services, it is imperative that you be careful when traveling with client documentation. Be mindful of confidentiality laws. Carry as little client data and documents as you need while you travel. Whatever you do travel with should be carefully stored such as by locking it in a secure location.
Documentation and Reporting Key Terms
Clinical Direction
Clinical Direction means the communication between a supervisor and the RBT with regard to the implementation of intervention plans. The RBT must communicate any concerns or issues regarding plan implementation and the supervisor must provide the relevant direction and support to the RBT.
Session Notes
A session note is written to record the events of an RBT?s session with a client. Session notes should indicate the tasks that were completed, what reinforcers were used and the level of prompting that was required for tasks. Behaviors that challenge might also be reported. When writing a session note, avoid using subjective terms and use professional language. If there are other concerns that may be related to setting events (e.g. low appetite, appearing tired or upset) these should also be objectively reported.
Data Protection
Data protection is the process of safeguarding important personal information from corruption, compromise or loss. It can relate to what information is collected and how it is stored or transported. It may also related to how and with whom data is shared. RBT?s have a duty to protect their client?s data.