Session Notes
A session note is a detailed summary of what occurred during your session and how it impacts the learner's overall progress.
Aside from complying with insurance funders' requirements, session notes help team members gain a better visualization of what occurred in each session, to support clinical decision-making regarding modifications to interventions in the care plan.
For information about how session notes are saved and exported by your organization, see Export Session Notes.
Direct Care Sessions
Clinical walk-through video of how to complete a session note, with examples:
Or click here to watch the tutorial.
After collecting data on your direct care session, complete the session note before submitting your session.
There are 5 sections in a direct care session note:
Participants: Select and add the participants who were present at your session.
Intervention Techniques: Review the intervention technques configured on targets addressed during the session. If all intervention techniques were used, leave as is. If some intervention techniques weren't used, deselect them from the list.
This section does not appear on your session note when no intervention techniques were configured for targets addressed during your session.
Session Insights: Review the data you collected during your session to understand how it affects the overall progress for each target. Data you collected during your session will fall under one of the following categories:
- Improving Scores: higher scores than the previous data point for that target.
- Regressing Scores: lower scores than the previous data point for that target.
- Incomplete Scores: scores where the minimum trials configured by the BCBA for that target were not collected.
- Problem Behaviors: behaviors that occurred during the session.
Setting Events: Include observable and measurable details that may have interfered with your session or possibly impacted the increase in occurrence or intensity of problem behaviors.
Preferences and Reinforcers: Include observable and measurable details about the preferences and reinforcers utilized during the session.
After completing the session note, tap "Review Session Note" to generate a session narrative based on the information you entered on the note. Edit and add detail to ensure it accurately summarizes your session, then save the note.
BCBA Sessions
Or click here to watch the tutorial.
After completing your session and making any changes to the care plan that you'd like to mention in your session note, complete the session note before submitting your session.
There are 3 sections in BCBA session notes:
- Participants: Select and add the participants who were present at your session. You can include names of additional participants in parentheses after the title of the participant: "Sister (Alice Smith)", "Father (Bob Smith)."
- Session Summary: This section shows common tasks done during the service you completed. Select the tasks you did during your session, and add detail where prompted.
- Some tasks allow you to reference targets added to the care plan, updates to targets, or scores collected on the date of the session. On Supervision sessions, you will also be able to reference scores collected by the Behavior Technician during the timing of your session.
- Barriers to Treatment: Describe any barriers to treatment that occurred or were identified during your session.
After completing the session note, tap "Review Session Note" to generate a session narrative based on the information you entered on the note. Edit and add detail to ensure it accurately summarizes your session, then save the note.