What Are Session Notes?
Session notes also allow staff and other members of an organization to refer back to services provided on any given day and see progress, problematic behavior, incidents that may have occurred, interventions used, and an overall summary of the client’s day. Other items included on session notes can include the clinician who worked with the client, the amount of time the client was in our care, individuals who were involved in the session, and the client’s response to treatment. Session notes allow companies to review the treatment being provided and to verify service delivery. Consider this statement “If it wasn’t documented, it wasn’t done.”
After a tiring session, the last thing our staff wants to do is to sit down and write about what happened, especially since they spent so much time collecting that amazing data, right? However, a well-written session note goes a long way to helping supervisors adjust programs as needed. And if you have had your session notes audited by an insurance company (for potential recoupment) you know how stressful (and painful) this process can be.
The struggle is real...
As an ABA therapist, getting caught up in the world of therapy with all the jargon, techniques, and data can be easy.
It’s not uncommon to slip into clinical language and forget that we are working with real people--and that our treatment plans and notes can have a huge impact on their progress.
We at Sage Learning Systems know that one of the most crucial pieces of documentation we create as therapists is ABA session notes. They serve as a snapshot of every session and outline the successes, challenges, and areas to focus on moving forward.
For that, let us share the importance of detailed ABA session notes and some tips and tricks to ensure you’re documenting effectively.
Why Are Session Notes Important?
Can be used to substantiate (verify) ABA billing claims for payors (ensuring timely and accurate payment for services rendered)
Are required by many payors/insurance companies (e.g., compliance with regulations and contracts; helps to reduce malpractice risks)
Communicate the need for ongoing services
Help to maintain continuity of care for clients
Provide documentation in case of an audit (internal or external)
Help providers plan for treatment and make changes (evaluate progress)
Are a part of the client’s medical record
Ensure progress is noted (data collection is insufficient for a medical record)
Are required by the BACB (i.e., RBT Task List (2nd ed); Task List Item E-4)
Potential Outcomes of Poor Session Notes
Unfortunately, poorly written session notes can have a negative impact on both providers and the client.
What are the Benefits of Accurate and Comprehensive ABA Session Notes?
Detailed and comprehensive session notes clarify necessary adaptations to existing techniques to better match the client's needs.
This data also allows providers to review client progress and ensure consistent efforts in addressing the client's behavior across sessions and staff.
Plus, it provides clarity to team members regarding the therapy's effectiveness and informs insurance providers about the client's progress.
How to Write ABA Session Notes
As with all things in behavior analysis, we need to operationally define what a “good” session note entails. A “good” session note has enough information for the rendering provider and the payor to get a sense of what happened in the session and includes data from the programs implemented during the session in a manner that is easy to assess and compare to other sessions and has all of the required components identified by the payor. Make sure to include the session note essentials, for both clinical and non-clinical items in your notes.
Tips on How to Write 'Good' ABA Session Notes
1. Be Objective
Avoid interpretations or assumptions about a client's behavior, use "observable" information only.
2. Be Accurate
Ensure that you include detailed behavior descriptions of what occurred during the session.
3. Be Timely
Record all details immediately after the session to ensure the accuracy of the session note details.
4. Be Specific
Use precise and measurable terms to define the behavior and progress of the client
5. Be Transparent
Write in a manner that a person with no ABA therapy background can understand.
6. Be Consistent
Standardize your words and language to make the notes easily understandable by any reader.
7. Be Organized
Arrange the note's format to make it easy to locate essential information.
Strategies for Writing the Narrative Section of the Session Note
At SAGE Learning Systems, we have developed a systematic 4-part framework for writing the narrative section of the session note…which staff continually report as being the most difficult and stressful section to write about after a long and tiring session. There are four components to the 4-part framework that ensure staff includes all information needed to document the medical necessity of the ABA services provided, as well as update progress over time.
Staff are trained to use the 4-part framework to reduce the amount of time it takes them to write session notes (comprehensive and detailed notes can be completed in 10 minutes), increase the accuracy of detailing session activities as it relates to the client’s treatment goals, and ensure that the services provided reflect the medical necessity of services for the client.
First, they select a treatment goal (skill acquisition or behavior reduction) to write about. Second, they identify the evidence-based practice (intervention) that they used. Third, they relate this back to the DSM-5 core symptoms for ASD (the client’s treatment goals are written in a way that references this for technicians). Finally, they summarize the client’s progress observed in this session (review the data) from the last session.
Let’s Put That All Together…
Here is an example of the narrative section of the session note (color-coded to make it easier for you to identify the four components of the SAGE framework system). Looks good, right?! Yes, this was written by a technician. No, seriously. They receive training and resources which are designed to ensure they have the skills to write “good” ABA session notes.
Want to Learn More About Our Training?
If you are tired of doing…all…of…the…things to try and figure out what is needed to demonstrate medical necessity, make sure you are in compliance with payor requirements, and ensure your ABA session note audits pass without funds being recouped…this master class is for you! Help your staff go from confused to confident in 3.5 hours and earn CEUs while doing so!
Don’t have time to create an ABA session note system to track, review, and ensure compliance with payors?
Our Complete Session Note Bundle resource is essential for clinicians just starting out, as well as for more seasoned clinicians who are looking to make sure their ABA session notes demonstrate medical necessity and ensure compliance with payor requirements and contracts.
Resources are provided for the 97151, 97153, 97155, and 97156 codes.
✏️ Session note templates
✏️ Session note templates (+ written guidance/support)
✏️ Self-monitoring checklist
✏️ Barriers to progress document
✏️ Quality assurance measures
✏️ Session note audit tracker
✏️ Written narrative examples
✏️ Writing support resources
🌟 Free bonus material!
Have you downloaded your FREE 97153 Session Note Checklist yet?
If not...get it here! https://www.sagelearningsystems.com/freechecklist