Incident Reports in ABA

Incident reports document unusual or significant events that occur during ABA services. As an RBT, you’ll be responsible for completing these reports when specific situations arise. Proper incident documentation is essential for client safety, risk management, quality improvement, and legal protection.

Purpose of Incident Reports

Incident reports serve several important functions:

1. Safety and Risk Management

Identifying hazards: Documenting conditions that create risk
Tracking patterns: Recognizing recurring safety concerns
Preventing recurrence: Informing preventive measures
Response evaluation: Assessing effectiveness of safety procedures
Environmental modifications: Guiding changes to physical settings

2. Clinical Information

Behavior triggers: Identifying antecedents to significant behaviors
Intervention effectiveness: Evaluating response to crisis situations
Treatment planning: Informing modifications to behavior plans
Progress monitoring: Tracking changes in severity or frequency
Functional assessment: Contributing to understanding behavior function

3. Administrative and Legal Requirements

Regulatory compliance: Meeting reporting mandates
Insurance documentation: Providing information for claims
Legal protection: Creating contemporaneous record of events
Quality assurance: Supporting program evaluation
Communication: Informing stakeholders of significant events

Types of Reportable Incidents

Different organizations may have varying definitions of reportable incidents, but most include these categories:

1. Injury or Illness

Physical harm or medical concerns that occur during service delivery.

Examples:

Client injury requiring first aid or medical attention
Staff injury during service provision
Sudden illness or medical emergency
Seizures or other medical events
Allergic reactions

Documentation focus:

Nature and extent of injury/illness
First aid or medical care provided
Circumstances surrounding the event
Staff response and notifications made
Follow-up care recommendations

2. Behavioral Incidents

Serious challenging behaviors that pose risk or require significant intervention.

Examples:

Aggression resulting in injury
Self-injury requiring intervention
Property destruction of significant value
Elopement (leaving supervised area)
Suicidal statements or actions

Documentation focus:

Antecedents to the behavior
Detailed description of the behavior
Interventions implemented
Duration and intensity
Resolution and aftermath
Function hypothesis

3. Environmental Incidents

Events related to the physical environment that affect safety or service delivery.

Examples:

Damage to service setting
Exposure to hazardous materials
Fire or natural disaster
Power outage affecting services
Unsafe conditions discovered

Documentation focus:

Nature of environmental issue
Impact on service delivery
Safety measures implemented
Relocation if necessary
Resolution timeline

4. Medication Incidents

Events related to medication management or administration.

Examples:

Medication administration errors
Adverse medication reactions
Missed medication doses
Unauthorized medication consumption
Medication refusal

Documentation focus:

Medication details (name, dose, time)
Nature of the incident
Client response/symptoms
Medical consultation obtained
Corrective actions taken

5. Confidentiality Breaches

Incidents involving improper disclosure of protected information.

Examples:

Loss of client records
Unauthorized access to information
Accidental disclosure of private information
Electronic data breach
Improper disposal of confidential documents

Documentation focus:

Nature of the breach
Information involved
Persons affected
Containment measures
Notification procedures followed

6. Abuse/Neglect Allegations

Claims of mistreatment that require formal reporting and investigation.

Examples:

Allegations against staff
Allegations against family members
Observed signs of possible abuse/neglect
Client disclosure of mistreatment
Inappropriate interactions observed

Documentation focus:

Factual observations only
Direct quotes when possible
Reporting actions taken
Protective measures implemented
Agency contacts notified

Components of a Complete Incident Report

A thorough incident report includes several essential elements:

1. Basic Information

Identifying details about the incident, client, and reporter.

Required elements:

Date and time of incident: When the event occurred
Date and time of report: When documentation was completed
Location: Where the incident took place
Client information: Name, ID, date of birth
Reporter information: Name, position, contact details
Witnesses: Others present during the incident
Service type: What services were being provided

2. Objective Description

Factual account of what occurred without interpretation or opinion.

Required elements:

Chronological sequence: Step-by-step account of events
Observable behaviors: What was directly witnessed
Direct quotes: Exact words spoken when relevant
Measurable details: Duration, frequency, intensity
Environmental factors: Setting conditions and context
Others involved: All persons participating or present
Immediate outcomes: Direct results of the incident

3. Response and Intervention

Actions taken to address the incident and ensure safety.

Required elements:

Immediate response: First actions taken
Safety measures: Steps to protect all involved
First aid/medical care: Health interventions provided
Crisis procedures implemented: Specific protocols followed
De-escalation techniques: Methods used to resolve situation
Environmental modifications: Changes made to setting
Additional resources: Outside help requested

4. Notifications and Reporting

Communication with relevant parties about the incident.

Required elements:

Internal notifications: Supervisors, administrators informed
External reporting: Regulatory agencies contacted
Family/guardian contact: When and how caregivers were notified
Medical providers: Healthcare professionals consulted
Emergency services: Police, fire, or ambulance involvement
Mandatory reporting: Abuse/neglect reporting if applicable
Follow-up communication: Subsequent updates provided

5. Analysis and Prevention

Assessment of contributing factors and plans to prevent recurrence.

Required elements:

Antecedent analysis: Events leading to the incident
Risk factors: Conditions that contributed to occurrence
Pattern identification: Relation to previous incidents
Preventive strategies: Plans to reduce future risk
Staff training needs: Skill development required
Environmental changes: Setting modifications needed
Procedure revisions: Updates to protocols recommended

6. Follow-up Actions

Plans for addressing aftermath and monitoring outcomes.

Required elements:

Medical follow-up: Healthcare appointments scheduled
Monitoring procedures: Observation plans for client
Treatment modifications: Changes to intervention plans
Team meeting: Collaborative review scheduled
Additional assessments: Further evaluation needed
Environmental inspection: Setting safety review
Documentation review: Analysis of related records

7. Administrative Elements

Formal components required for official documentation.

Required elements:

Report identifier: Tracking number or code
Signatures: Reporter, supervisor, administrator
Review dates: When report was examined
Classification: Incident category designation
Severity rating: Level of seriousness assessment
Attachments: Related documents or photographs
Distribution list: Who received copies of report

Writing Effective Incident Reports

Objective vs. Subjective Documentation

Incident reports must focus on observable facts rather than opinions or interpretations.

Subjective vs. Objective Examples:

Subjective	Objective
”Client was aggressive and angry"	"Client hit peer on arm with closed fist and said ‘I hate you’"
"Staff handled the situation poorly"	"Staff implemented crisis protocol by removing other clients and using verbal de-escalation"
"Client had a severe tantrum"	"Client cried loudly, fell to floor, and kicked legs for 5 minutes"
"Medication made client sick"	"Client vomited twice within 30 minutes of medication administration"
"Parent was negligent"	"Client arrived with same clothes as yesterday, unwashed, and reported not having eaten breakfast”

Specific and Detailed Documentation

Incident reports require precise information to be useful for analysis and follow-up.

Vague vs. Specific Examples:

Vague	Specific
”Client got hurt during session"	"Client sustained 2-inch laceration on right forearm when arm contacted edge of desk during transition"
"Behavior plan was implemented"	"Two-person escort was used per behavior intervention plan, section 3.2, for 45 seconds until client was seated in designated calming area"
"Parent was called about the incident"	"Mother was contacted by phone at 2:15 PM, informed of incident, and arrived at center at 2:45 PM to take client to urgent care"
"Client took the wrong medication"	"Client received 10mg Ritalin prescribed for another client instead of prescribed 5mg Ritalin at 9:00 AM medication administration"
"Environmental factors contributed"	"Fire alarm sounding at 1:30 PM created sudden loud noise and flashing lights immediately preceding behavioral incident”

Chronological and Complete Documentation

Incident reports should present events in time sequence and include all relevant details.

Example of Complete Chronological Documentation:

10:15 AM: Client arrived at therapy room for scheduled session.
10:20 AM: Session began with preference assessment.
10:25 AM: Client requested iPad, which was unavailable due to charging.
10:26 AM: Client vocalized "I want iPad" and was offered alternative choices.
10:27 AM: Client pushed materials from table and attempted to leave room.
10:28 AM: RBT blocked doorway and implemented verbal de-escalation per BIP.
10:29 AM: Client hit RBT on right arm with closed fist.
10:30 AM: Second staff entered room to assist; supervisor notified.
10:31 AM: Client guided to calming corner using two-person escort as specified in BIP.
10:35 AM: Client began to calm; deep breathing techniques introduced.
10:40 AM: Client fully calm; supervisor conducted brief assessment.
10:45 AM: Session resumed with modified activities.
10:50 AM: Parent notified by phone of incident by supervisor.
11:15 AM: Session completed without further incident.
11:20 AM: Parent arrived for pickup; in-person debrief provided.

Professional and Neutral Language

Incident reports should use professional terminology and avoid emotional or judgmental language.

Unprofessional vs. Professional Examples:

Unprofessional	Professional
”Client went crazy when told no"	"Client exhibited escalated behavior when preferred item was unavailable"
"Mom doesn’t care about following through"	"Parent reported being unable to implement recommended strategies at home"
"Staff couldn’t handle the situation"	"Additional staff assistance was required to implement safety procedures"
"Client was manipulative and attention-seeking"	"Client’s behavior increased when staff attention was directed elsewhere"
"The stupid fire alarm set everything off"	"Unexpected fire alarm activation preceded behavioral escalation”

Legal and Ethical Considerations

Confidentiality and Privacy

HIPAA compliance: Adhere to privacy regulations
Secure storage: Protect physical and electronic reports
Need-to-know distribution: Share only with authorized personnel
De-identification when appropriate: Remove unnecessary identifiers
Secure transmission: Use encrypted methods for electronic sharing

Mandatory Reporting Requirements

Abuse and neglect: Know reporting obligations
Timeframes: Understand required reporting windows
Agency procedures: Follow organizational protocols
Documentation of reports: Record all reporting actions
Follow-up requirements: Complete required subsequent steps

Documentation Timing

Immediate notes: Jot key details as soon as possible
Formal report timing: Complete full documentation promptly
Regulatory timeframes: Adhere to required submission deadlines
Late reporting procedures: Follow protocols if delays occur
Documentation of timing: Record when events and reporting occurred

Record Retention

Storage requirements: Follow agency policies for keeping reports
Retention periods: Maintain records for required timeframes
Secure archiving: Protect historical incident documentation
Retrieval systems: Ensure access when needed
Destruction protocols: Follow proper procedures for disposal

Common Incident Report Errors

1. Incomplete Information

Problem: Missing essential details needed for understanding or follow-up.

Examples:

Omitting time of incident
Failing to document notifications made
Missing description of interventions used
Incomplete listing of witnesses
Lack of follow-up actions

Solution:

Use standardized forms with required fields
Implement review process before submission
Create checklist of essential elements
Train staff on documentation requirements
Establish quality assurance review

2. Delayed Reporting

Problem: Excessive time between incident and documentation.

Examples:

Completing report days after incident
Missing regulatory reporting windows
Delayed notification to supervisors
Late communication with family
Postponed follow-up documentation

Solution:

Establish clear timeframe expectations
Provide immediate documentation tools
Create interim reporting mechanisms
Implement escalation for missed deadlines
Monitor compliance with timing requirements

3. Inappropriate Subjectivity

Problem: Including opinions, judgments, or interpretations rather than facts.

Examples:

Assigning motivation to behaviors
Including emotional reactions to incident
Making assumptions about intentions
Offering unsubstantiated conclusions
Using judgmental terminology

Solution:

Train on objective documentation
Implement peer review process
Provide examples of objective language
Create templates with objective prompts
Establish editorial review for subjective content

4. Defensive Documentation

Problem: Writing that appears to defend actions rather than report objectively.

Examples:

Overemphasis on staff correct actions
Minimizing negative outcomes
Omitting potentially unfavorable details
Excessive justification of decisions
Deflecting responsibility to others

Solution:

Focus training on factual reporting
Separate incident reports from performance issues
Create culture of learning from incidents
Implement neutral review process
Emphasize improvement over blame

5. Inconsistent Documentation

Problem: Contradictions between different sections or reports.

Examples:

Different times reported in various sections
Conflicting accounts of same events
Inconsistent terminology for behaviors
Varying descriptions of interventions used
Contradictory follow-up recommendations

Solution:

Implement chronological documentation
Use consistent terminology across reports
Create integrated documentation systems
Review for internal consistency
Consolidate multiple observer accounts

Incident Report Systems and Workflows

Paper-Based Systems

Traditional hardcopy documentation of incidents.

Components:

Standardized forms: Consistent format for all incidents
Multiple copies: Distribution to required parties
Routing procedures: Process for review and approval
Filing systems: Organization of physical documents
Tracking logs: Record of all reported incidents

Workflow:

Incident occurs and immediate response provided
Staff obtains incident report form
Initial documentation completed as soon as possible
Report submitted to supervisor for review
Supervisor adds comments and signs
Copies distributed according to protocol
Original filed in designated location
Follow-up documentation added as needed
Periodic review for quality assurance
Long-term storage according to retention policy

Electronic Incident Reporting

Digital systems for documenting and tracking incidents.

Components:

Electronic forms: Digital documentation templates
Automated routing: Electronic submission to reviewers
Notification systems: Alerts to required personnel
Integration: Connection with client records
Reporting capabilities: Data analysis functions

Workflow:

Incident occurs and immediate response provided
Staff logs into electronic system
Digital form completed with required fields
System validates essential information
Report automatically routed to supervisor
Electronic notifications sent to required parties
Digital review and approval process
Electronic storage in client record
Automated reminders for follow-up actions
Data aggregation for trend analysis

Incident Review Process

Systematic examination of incidents for quality improvement.

Components:

Initial review: Supervisor assessment of report
Team review: Collaborative examination of serious incidents
Root cause analysis: Systematic investigation of factors
Trend identification: Pattern recognition across incidents
Improvement planning: Development of preventive strategies

Workflow:

Incident report received by review authority
Initial assessment of severity and classification
Assignment to appropriate review level
Investigation of contributing factors
Team discussion for serious incidents
Development of recommendations
Implementation of preventive measures
Follow-up to ensure effectiveness
Documentation of review process
Periodic aggregate analysis of incidents

Practice Example

An RBT is working with a 10-year-old client with autism who has a behavior intervention plan for aggression. During a session, the client becomes upset when a preferred activity ends and hits the RBT on the arm, causing a bruise. The RBT implements the crisis protocol from the behavior plan, and the situation is resolved after 10 minutes.

Question: What should be included in the incident report for this situation?

Solution:

Comprehensive Incident Report:

INCIDENT REPORT

Basic Information:

Date of Incident: 10/15/2023
Time of Incident: 2:30 PM
Date of Report: 10/15/2023
Time of Report: 4:00 PM
Location: Therapy Room 3, ABC Therapy Center
Client: John Smith (ID #12345)
Client DOB: 5/12/2013
Reporter: Mary Johnson, RBT (Certification #RBT-000)
Witnesses: David Chen, RBT; Susan Wong, BCBA (observed partial incident)
Service Type: Individual ABA Therapy Session

Incident Classification:

Type: Behavioral Incident with Staff Injury
Severity Level: Moderate (required first aid, no medical treatment)

Objective Description: At 2:30 PM, client was informed that his 15-minute iPad time was ending. Timer was shown to client indicating zero time remaining. Client said “No, more time” and held onto iPad. RBT provided verbal prompt, “iPad time is finished, time for math activity.” Client released iPad but then hit RBT on right upper arm with closed fist one time. Hit was of moderate force and caused immediate redness to the area. Client then attempted to grab iPad back while saying “I want it” in elevated voice. Client then hit the table surface twice with open palm and attempted to leave the therapy room.

Response and Intervention: RBT implemented crisis protocol as specified in client’s BIP. RBT maintained calm tone and neutral facial expression, blocked access to iPad, and provided verbal direction, “Hands down, take a deep breath.” Second staff (David Chen, RBT) entered room to assist. Client was directed to calming corner using gestural prompts. No physical intervention was required. Client complied with direction to calming corner. Deep breathing visual support was provided. Client engaged in deep breathing for approximately 2 minutes. After 5 minutes in calming area, client was calm (quiet voice, relaxed body posture, following directions). Client was then offered choice of two alternative activities (math game or reading). Client chose math game and transitioned successfully. Session continued without further incident.

Injury Assessment: RBT sustained bruise to right upper arm, approximately 2 inches in diameter. First aid provided: ice pack applied for 10 minutes. No medical treatment required. Injury documented with photograph (attached) with client identifiers removed. Pain level reported as 2/10 by RBT.

Notifications:

BCBA Supervisor (Susan Wong): Notified in person at 2:35 PM during incident
Program Director (James Taylor): Notified by email at 3:00 PM
Client’s Parent (Mrs. Smith): Notified by phone at 3:15 PM by BCBA
Incident Report System: Entry completed at 4:00 PM

Analysis and Prevention: Antecedent: Transition from preferred activity (iPad) to non-preferred activity (academic work) Possible function: Access to preferred item/activity Contributing factors: Client had shortened sleep last night per parent report at drop-off Pattern identification: Similar incident occurred on 9/30/2023 during transition from computer time

Preventive strategies:

Implement visual countdown timer with 5-minute and 1-minute warnings
Provide visual schedule showing iPad time followed by preferred activity, then academic work
Teach appropriate request for “more time” using communication card
Consider shorter work periods followed by brief preferred activity access

Follow-up Actions:

BCBA to review and potentially modify transition procedures in BIP by 10/18/2023
Additional staff training on transition strategies scheduled for 10/20/2023
Parent meeting scheduled for 10/17/2023 to discuss consistent transition strategies
Follow-up on RBT injury status to be documented by 10/16/2023
Team meeting to review incident scheduled for 10/19/2023

Administrative Elements:

Report ID: INC-2023-156
Completed by: Mary Johnson, RBT
Reviewed by: Susan Wong, BCBA (10/15/2023)
Approved by: James Taylor, Program Director (10/16/2023)
Attachments: 1) Photograph of injury 2) ABC data collection form
Distribution: Client file, Incident database, Risk management, BCBA supervisor

This comprehensive incident report provides a complete, objective account of the event, the response, all notifications made, analysis of contributing factors, and specific follow-up actions. It focuses on observable behaviors and factual information while avoiding subjective interpretations or judgments.

Key Points to Remember

Incident reports document unusual or significant events that occur during ABA services
Reports should be objective, specific, and chronological
Include all required components: basic information, description, response, notifications, analysis, and follow-up
Complete documentation as soon as possible after the incident
Use professional, neutral language and avoid subjective interpretations
Follow organizational and regulatory requirements for reporting timeframes
Understand mandatory reporting obligations for abuse and neglect
Maintain confidentiality while sharing information with appropriate parties
Use incident reports as tools for quality improvement and risk management
Document follow-up actions and preventive strategies
Review incidents for patterns that may inform program improvements
Adhere to record retention policies for incident documentation