RBT Exam Revision Course: Documentation and Reporting

Section E: Documentation & Reporting – Overview

Documentation and reporting are critical parts of an RBT’s responsibilities. This section prepares you to record data accurately, report changes clearly, and communicate effectively with your team and supervisor. Good documentation ensures continuity of care, protects client rights, and upholds ethical and professional standards.

This section will help you learn:

  • How to objectively describe client behaviour and skill performance
  • What to document and how to maintain accurate records
  • How to report changes in client status to your supervisor
  • How to follow proper documentation procedures (e.g., session notes, incident reports)
  • Why confidentiality and professional conduct are vital in written records

Use the collapsible sections below to review each Task List item. You can:

Table of Contents

E-01: Effectively Communicate with Supervisor

Effective communication with your supervisor ensures that interventions are implemented correctly and client progress is monitored accurately. Clear, timely, and professional communication allows for adjustments to be made when necessary.

E-02: Actively Seek Clinical Direction

Supervisors provide clinical guidance to ensure that interventions are appropriate and effective. RBTs should seek feedback proactively, follow supervisor recommendations, and address any concerns about intervention plans without delay.

E-03: Report Relevant Variables

RBTs must report changes in a client’s routine, health, medication, sleep patterns, or other factors that may impact behavior. These changes function as setting events, influencing how interventions should be applied and how data should be interpreted.

E-04: Generate Objective Session Notes

Session notes should be objective, factual, and professional, providing a clear record of what occurred during the session. Notes should describe:

  • Any setting events that might have affected behavior
  • The interventions implemented
  • Skill acquisition progress, including success rates
  • Any challenging behaviors observed, described in measurable terms

E-05: Comply with Data Requirements

RBTs must follow data protection laws relevant to their jurisdiction. This includes securely storing, handling, and transporting client records to maintain confidentiality. Always:

  • Store session notes and data securely
  • Minimize travel with client documentation
  • Comply with HIPAA (US), GDPR (UK/EU), or other local privacy laws

Glossary of Key Terms

Ongoing communication between an RBT and a supervisor regarding intervention implementation. Supervisors provide guidance, modifications, and support as needed.

A factual record of an RBT session, including skills taught, prompting levels, reinforcers used, behaviors observed, and any setting events.

Ensuring client data is secure from loss, corruption, or unauthorized access. Includes limiting access, secure storage, proper transport, and compliance with legal regulations.

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