Session note
The written record of a service session describing objectively what occurred, including services delivered, client responses, relevant events and any required details for legal, payer and workplace requirements.
A session note documents what happened during a session. Its exact format depends on the employer, funder and applicable laws, but notes commonly include the date, start and end times, location, people present, the targets and procedures worked on, a summary of the client's responses or data, notable events such as problem behavior, injuries, illness or changes reported by caregivers, and the RBT's signature. Many organizations require notes to be completed the same day.
Session notes must be objective. They describe what was seen and heard in observable, measurable terms, not guesses about feelings, motives or diagnoses. "Client cried for 6 minutes after the tablet was removed" is objective; "Client was manipulative and had a meltdown" is not. Reports from others are written as reports ("Caregiver stated...").
Session notes are often legal and billing records. The RBT Ethics Code (2.0) requires RBTs to accurately complete all required documentation, such as client data and billing records, and to be honest in all communications. Writing a note for a session that did not occur, changing times, or reusing another session's note as if it described this one are serious ethical and legal violations. Notes also contain confidential information and must be stored and shared only as workplace and privacy rules allow.
If a note needs to be corrected, the RBT follows the workplace's correction procedure rather than deleting or rewriting the original, and tells the supervisor about any error that affects billing or records.
Example and non-example
| Example | "Session 3:00-5:00 p.m., client's home. Caregiver reported client slept 4 hours. Ran 6 targets; mand for 'help' 8/10 independent. Hit table 3 times during writing; plan followed. No injuries." |
|---|---|
| Non-example | "Great session! Client was happy and did awesome. Some attitude during writing but handled it." This is vague, subjective and missing the required details. |
Don't confuse it with
| ABC data | ABC data record antecedents, behaviors and consequences for assessment, while a session note summarizes the whole session for records and billing. |
|---|---|
| Behavior intervention plan (BIP) | A behavior intervention plan describes what should be done, while the session note documents what was actually done and what happened. |
Test yourself
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Question 1Which session note describes a school-age client's behavior objectively?
Show answer
C: Pushed the worksheet off the table and said "no". This note reports exactly what the client did and said, so anyone reading it knows what happened without having to interpret.
- A: Frustration is an inferred feeling, not an observed action.
- B: This guesses at the reason for the behavior instead of describing it.
- D: "Bad attitude" is a judgment that does not say what the client did.
Task A.5 · 40-hour curriculum section C
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Question 2An RBT writes that a client "stimmed during circle time." Which revision describes the behavior in observable terms?
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A: Flapped both hands at shoulder height for 5 s. The revision states the body part, the movement, its position and how long it lasted, so a reader knows exactly what happened.
- B: This replaces one label with another and still does not describe the movement.
- C: This adds a guess about the behavior's function rather than describing it.
- D: "Repetitive behaviors" could mean many different movements.
Task A.5 · 40-hour curriculum section C
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Question 3A caregiver reports that a client slept poorly. Which session note entry is objective?
Show answer
B: Caregiver reported the client slept 4 hours last night. This states what was reported and who reported it, without adding the writer's interpretation. Sleep changes are worth noting because they can affect behavior.
- A: "Exhausted" and "cranky" are judgments, not descriptions of behavior.
- C: This claims a cause that a session note cannot establish.
- D: "Seemed off" is vague, and the link to sleep is a guess.
Task A.5 · 40-hour curriculum section C
Answer every question to see your score.
On the RBT exam
This term belongs to task E.4 Objective session notes in content area E, Documentation and Reporting, which is 10 of the 75 scored questions.