As a Behavior Technician (BT), your session notes aren’t just “paperwork”—they’re the single most detailed record of what happened during your time with each learner. Well‑written, objective notes ensure continuity of care, compliance with regulations, and clear communication with supervisors and families. Here’s how to make every entry count.
1. Stick to What You See and Hear
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Describe concrete behaviors:
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✔️ “Johnny engaged in 3 instances of hitting and 4 tantrums.”
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❌ “Johnny was bad today.”
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Report direct quotes:
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✔️ “Caregiver said, ‘He stayed up late last night.’”
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❌ “I think he was tired.”
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Avoid interpretations or feelings: Leave judgments (“He was frustrated”) out—stick to observable facts (“He sighed loudly and covered his ears”).
2. Use Professional, Consistent Language
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Neutral terms over colloquialisms:
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Say “task refusal” instead of “stubborn.”
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Clear data points:
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Include trial counts, percentages, latency or duration measures when relevant.
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Standard abbreviations:
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If your agency uses “SD” for discriminative stimulus or “FA” for functional analysis, use those consistently.
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3. Know Your Regulatory & Funding Requirements
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Setting matters:
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Schools, clinics, and home programs each have different note‑taking rules, session‑length minimums, and funding restrictions.
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Funding source differences:
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Medicaid or insurance‑funded therapy may require specific progress indicators; grant‑funded programs might need different goal formats.
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Ask your supervisor:
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Keep a quick reference of each payer’s documentation checklist so you never miss a required field.
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4. When to File an Incident Report
Not every scribble in your notes becomes an “incident,” but some events demand formal documentation:
| Scenario | Action |
|---|---|
| Learner bites staff drawing blood | Complete an Incident Report immediately |
| Learner falls and sustains a bruised knee | File an Incident Report and notify supervisor |
| Any unexpected medical or safety concern | Report per your agency’s critical‑incident policy |
Even minor mishaps can signal a need to adjust supports or environmental controls—so err on the side of caution.
5. Build a Simple, Reusable Template
Having a go‑to structure guarantees you capture every critical detail:
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Session Info: Date, time, setting, staff present
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Goals & Targets: What skills or behaviors you worked on
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Objective Data: Correct/incorrect trials, frequency, duration
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Ecological Variables: Sleep, medication changes, caregiver updates
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Notes: Concrete observations—avoid opinions
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Next Steps: Suggested adjustments, materials needed
Tip: Use shared digital forms (Google Docs, Catalyst) so supervisors can review and comment in real time.
In Summary
Objective session notes are your strongest tool for ensuring fidelity, compliance, and learner success. By focusing on observable facts, using professional language, adhering to your program’s regulations, knowing when to file incident reports, and leveraging a consistent template, you’ll make your notes clear, actionable, and invaluable to your entire team.
Action Step: Draft or revise your session‑note template today—then ask your supervisor for a quick walkthrough to confirm you’ve covered every requirement. Clean, objective notes start now!