Session Notes in ABA

Session notes are detailed records of therapy sessions that document what occurred during service delivery. As an RBT, you’ll be responsible for creating accurate, objective, and comprehensive session notes that meet professional standards and compliance requirements. Well-written session notes are essential for tracking progress, communicating with team members, and meeting billing requirements.

Purpose of Session Notes

Session notes serve multiple important functions:

1. Clinical Documentation

Progress tracking: Documents client response to intervention
Implementation record: Shows which procedures were used
Behavioral observations: Records client behavior patterns
Skill acquisition: Tracks mastery of target skills
Consistency monitoring: Ensures procedures are implemented as designed

2. Communication Tool

Team information sharing: Keeps all providers informed
Supervision documentation: Provides information for BCBA review
Caregiver updates: Informs family members about progress
Interdisciplinary collaboration: Communicates with other professionals
Transition planning: Provides information for new team members

3. Administrative and Legal Record

Service verification: Documents that services were provided
Billing support: Justifies insurance claims
Compliance evidence: Demonstrates adherence to regulations
Legal protection: Provides record in case of disputes
Quality assurance: Allows for review of service quality

Components of Effective Session Notes

1. Basic Session Information

Essential identifying information that should appear in every note:

Client identifier: Name or ID number
Date of service: When session occurred
Time frame: Start and end times
Service location: Where session took place
Service type: Type of intervention provided
Provider information: Name and credentials of RBT
Supervision information: Name of supervising BCBA

2. Session Content

Detailed information about what occurred during the session:

Goals/objectives addressed: Which targets were worked on
Procedures implemented: Specific interventions used
Materials utilized: Resources and tools employed
Reinforcement systems: Motivational strategies used
Prompting levels: Types and frequency of prompts
Modifications made: Any adjustments to planned procedures
Novel situations: New circumstances or events

3. Client Response and Progress

Objective description of how the client performed:

Data summary: Brief overview of performance data
Skill acquisition: Progress on new skills
Behavioral incidents: Occurrence of challenging behaviors
Prompt dependency: Level of independence
Motivation patterns: Engagement and interest levels
Generalization observed: Skills demonstrated across settings/people
Maintenance demonstrated: Previously mastered skills retained

4. Analysis and Recommendations

Professional insights and next steps:

Patterns identified: Trends in performance or behavior
Barriers noted: Obstacles to progress
Effective strategies: Approaches that worked well
Suggested modifications: Recommended changes to procedures
Caregiver recommendations: Guidance for family implementation
Questions for supervisor: Issues requiring BCBA input
Next session plan: Focus for upcoming sessions

SOAP Note Format

The SOAP format is a structured approach to session documentation widely used in healthcare and therapeutic settings.

S - Subjective

Information reported by the client or others, not directly observed by the provider.

Examples:

“Parent reports client slept poorly last night”
“Teacher mentioned increased participation in group activities”
“Client stated he was excited about earning tokens”
“Mother indicated challenging behaviors occurred at home yesterday”
“Grandmother reported successful use of visual schedule at dinner time”

Guidelines:

Clearly attribute information to source
Use quotes when appropriate
Distinguish from your own observations
Include relevant contextual information
Document only pertinent subjective information

O - Objective

Factual, observable information directly witnessed by the provider.

Examples:

“Client completed 8/10 trials independently on matching task”
“Three instances of hitting occurred during transition times”
“Client maintained eye contact for an average of 3 seconds per interaction”
“Required gestural prompts for 60% of handwashing steps”
“Engaged with peer for 5 minutes during structured play activity”

Guidelines:

Include specific, measurable observations
Avoid interpretations or assumptions
Use clear, concrete language
Include quantitative data when possible
Document both target behaviors and contextual factors

A - Assessment

Professional analysis of the situation based on subjective and objective information.

Examples:

“Client is making steady progress on communication goals as evidenced by increased independent manding”
“Challenging behavior appears maintained by escape from demands based on ABC data”
“Prompt dependency observed during new tasks suggests need for prompt fading procedure”
“Inconsistent performance across settings indicates limited generalization”
“Rapid acquisition of target skills suggests readiness for more advanced goals”

Guidelines:

Connect observations to clinical significance
Reference behavior principles when relevant
Identify patterns and trends
Relate to treatment goals
Distinguish assessment from raw observations

P - Plan

Next steps and recommendations based on the assessment.

Examples:

“Will implement prompt fading procedure for self-help routine next session”
“Recommend increasing reinforcement schedule for independent work completion”
“Will introduce visual timer to address transition difficulties”
“Plan to probe generalization of greeting skills with unfamiliar staff”
“Will consult with BCBA regarding modification of token economy system”

Guidelines:

Be specific about next steps
Include timeline when appropriate
Address issues identified in assessment
Note any needed consultations
Specify changes to intervention approach

DAP Note Format

The DAP format is another structured approach to session documentation that is sometimes used in behavioral health settings.

D - Data

Objective information including both observed data and reported information.

Examples:

“Client completed 15/20 receptive identification trials correctly”
“Three episodes of tantrum behavior lasting 2-5 minutes each”
“Parent reports consistent use of visual schedule at home”
“Required full physical prompts for 4/10 steps of toothbrushing routine”
“Maintained on-task behavior for 10 minutes during academic work”

Guidelines:

Combine objective observations and reported information
Clearly distinguish between observed and reported data
Include quantitative measures when possible
Document both target behaviors and contextual factors
Report data in relation to goals and objectives

A - Assessment

Professional analysis of the client’s status and progress.

Examples:

“Client is showing increased independence in self-help skills”
“Attention-seeking function of behavior confirmed through systematic observation”
“Generalization of communication skills not yet evident across settings”
“Token economy appears effective in motivating task completion”
“Skill acquisition rate has plateaued over past three sessions”

Guidelines:

Interpret data in relation to treatment goals
Identify progress or lack thereof
Note factors affecting performance
Connect observations to clinical significance
Provide professional insights about patterns

P - Plan

Future direction and recommendations.

Examples:

“Will introduce visual supports for multi-step directions”
“Plan to conduct preference assessment to identify new reinforcers”
“Will begin teaching functional communication response to replace hitting”
“Recommend parent training on prompting procedures”
“Will consult with BCBA regarding potential goal modification”

Guidelines:

Outline specific next steps
Address issues identified in assessment
Include recommendations for other team members
Note any needed consultations or resources
Specify timeline for implementation when appropriate

Narrative Note Format

Some settings use a less structured narrative format for session documentation.

Components of Narrative Notes

Introduction: Brief overview of session context
Session activities: Description of interventions implemented
Client response: How the client performed and responded
Analysis: Professional interpretation of observations
Conclusion: Summary and next steps

Example Narrative Note:

“Session conducted at client’s home from 3:00-5:00 PM focusing on communication and self-help goals. Implemented mand training using picture exchange system during snack time. Client independently exchanged pictures for desired items on 7/10 opportunities, an improvement from 5/10 in previous session. Required partial physical prompts for remaining exchanges. Also worked on handwashing routine using backward chaining procedure. Client completed final three steps independently but needed full physical prompts for initial steps. Client appeared highly motivated by tablet time as reinforcer. Challenging behavior (pushing materials away) occurred twice during handwashing, which represents a decrease from previous sessions. Will continue current procedures for communication goals given steady progress. For handwashing, will consult with BCBA about implementing visual task analysis to reduce prompt dependency. Parent was trained on picture exchange procedure and will practice during meals at home.”

Guidelines for Narrative Notes:

Maintain structure: Follow a consistent format
Be concise: Include relevant information without unnecessary details
Balance comprehensiveness with brevity: Cover all important areas efficiently
Use professional language: Maintain clinical terminology
Include all essential elements: Ensure all required components are addressed
Focus on objectivity: Minimize subjective interpretations
Ensure readability: Use clear, well-organized writing

Writing Effective Session Notes

Use Objective Language

Objective language focuses on observable facts rather than subjective interpretations.

Subjective vs. Objective Examples:

Subjective	Objective
”Client was happy during the session"	"Client smiled and laughed throughout activities"
"Client was defiant"	"Client said ‘no’ and pushed materials away when presented with task"
"Had a great session"	"Client completed 90% of trials correctly and maintained engagement for 25 minutes"
"Client was unmotivated"	"Client required additional prompting and reinforcement to complete tasks"
"Parent doesn’t follow through at home"	"Parent reported implementing visual schedule 2/7 days since last session”

Be Specific and Measurable

Specific, measurable language provides clear information about what occurred.

Vague vs. Specific Examples:

Vague	Specific
”Worked on communication goals"	"Practiced requesting using PECS Phase II with 5 preferred items"
"Behavior was better today"	"Three instances of hitting occurred, down from seven in previous session"
"Made some progress"	"Independently completed 7/10 steps of task analysis, compared to 5/10 last week"
"Used prompting during activity"	"Required gestural prompts for 60% of trials and verbal prompts for 30%"
"Reinforced good behavior"	"Provided token reinforcement on FR3 schedule for on-task behavior”

Document Intervention Implementation

Clearly describe how procedures were implemented during the session.

Essential Elements to Document:

Specific procedures: Exact intervention techniques used
Procedural modifications: Any adaptations made to planned procedures
Implementation fidelity: How closely procedures followed the plan
Materials and settings: Environmental arrangements and resources used
Prompting strategies: Types and levels of prompts provided
Reinforcement systems: How reinforcement was delivered
Behavioral management: How challenging behaviors were addressed

Example: “Implemented differential reinforcement of alternative behavior (DRA) procedure for hitting. Provided immediate verbal praise and token reinforcement when client used ‘break’ card instead of hitting. Ignored instances of hitting (3 occurrences) and redirected to ‘break’ card. Modified reinforcement schedule from FR3 to FR2 after observing decreased motivation midway through session. Used visual timer to signal work periods and breaks as specified in behavior plan.”

Document Client Response

Clearly describe how the client responded to intervention.

Essential Elements to Document:

Performance data: Quantitative measures of target behaviors
Skill acquisition: Progress on learning targets
Behavioral incidents: Occurrence of challenging behaviors
Antecedents and consequences: Events surrounding behaviors
Motivation and affect: Engagement and emotional presentation
Novel responses: New or unexpected behaviors
Generalization: Performance across settings, people, or materials

Example: “Client demonstrated independent manding using picture cards for 8/10 opportunities with preferred items (up from 6/10 last session). When presented with non-preferred items, manding decreased to 3/10 opportunities. Two instances of pushing materials occurred during non-preferred activities, both following demands to complete worksheet. Client responded to redirection 1/2 times. Client spontaneously used ‘help’ card once when unable to open container, demonstrating generalization of this skill to novel situation. Client showed increased engagement with peer during parallel play activity, maintaining proximity for 5 minutes (baseline was 2 minutes).”

Address Progress Toward Goals

Connect session activities and observations to treatment goals.

Essential Elements to Document:

Goal-specific performance: Data related to formal goals/objectives
Baseline comparisons: Current performance vs. starting point
Rate of progress: How quickly skills are being acquired
Mastery status: Whether criteria have been met
Maintenance: Performance of previously mastered skills
Barriers to progress: Factors impeding advancement
Facilitators of progress: Factors supporting success

Example: “Goal 1: Independent toothbrushing - Client completed 7/10 steps independently (70%), approaching mastery criterion of 80% across 3 consecutive sessions. This represents steady progress from baseline of 30% independence. Client has maintained independence on steps 1-4 for two weeks and is now showing improvement on steps 5-7. Continued difficulty with step 8 (brushing back teeth) suggests need for modified approach to this specific step.

Goal 2: Functional communication - Client used appropriate vocal requests to replace screaming in 6/8 opportunities (75%), meeting mastery criterion for the second consecutive session. Will probe generalization with different staff members next session.”

Common Documentation Errors to Avoid

1. Insufficient Detail

Problem: Notes lack specific information needed to understand what occurred.

Examples:

“Worked on goals”
“Behavior was good”
“Used ABA techniques”

Solution:

Include specific interventions implemented
Provide quantitative data when possible
Describe behaviors in observable terms
Specify which goals were addressed
Document exact techniques used

2. Excessive Subjectivity

Problem: Notes contain opinions or interpretations rather than facts.

Examples:

“Client was uncooperative”
“Parent doesn’t care about following through”
“Had an excellent session”

Solution:

Focus on observable behaviors
Describe what happened, not why it happened
Use direct quotes when reporting statements
Separate observations from interpretations
Avoid judgmental language

3. Inconsistent Formatting

Problem: Notes lack consistent structure, making information difficult to find.

Examples:

Varying formats across sessions
Missing key components
Disorganized presentation of information

Solution:

Use consistent format (SOAP, DAP, or narrative)
Create template with all required elements
Follow agency guidelines for structure
Ensure all components are included
Organize information logically

4. Billing/Compliance Issues

Problem: Notes don’t meet requirements for service verification or reimbursement.

Examples:

Missing service codes
Inadequate justification for medical necessity
Lack of connection between service and treatment plan
Missing required signatures or credentials
Incomplete time documentation

Solution:

Know payer-specific requirements
Include all required billing elements
Clearly connect services to treatment goals
Document start/end times accurately
Ensure proper authentication of notes

5. Grammatical and Technical Errors

Problem: Poor writing quality reduces professionalism and clarity.

Examples:

Spelling and grammatical errors
Clinical jargon without explanation
Abbreviations not universally understood
Run-on sentences or fragments
Inconsistent terminology

Solution:

Proofread all documentation
Use spell-check and grammar tools
Define or avoid obscure abbreviations
Write clear, concise sentences
Maintain consistent terminology

Legal and Ethical Considerations

Confidentiality and Privacy

HIPAA compliance: Adhere to privacy regulations
Secure storage: Protect physical and electronic notes
Minimum necessary information: Include only relevant details
De-identification when appropriate: Remove unnecessary identifiers
Access limitations: Restrict note access to authorized personnel

Accuracy and Honesty

Truthful reporting: Document only what actually occurred
Error correction: Follow proper procedures for amending notes
Service verification: Accurately report services provided
Avoiding fabrication: Never create fictional information
Timely documentation: Complete notes promptly while recall is fresh

Professional Boundaries

Clinical focus: Maintain professional perspective
Appropriate content: Include only relevant information
Respectful language: Use dignified terminology
Cultural sensitivity: Respect diversity in documentation
Role delineation: Stay within scope of practice in assessments

Practice Example

An RBT has conducted a 2-hour session with a 6-year-old client focusing on communication skills and reducing tantrum behavior. The session included mand training, peer interaction activities, and one instance of tantrum behavior during a transition.

Question: Write an appropriate SOAP note for this session.

Solution:

SOAP Note Example:

Client: J.D.
Date: 10/15/2023
Time: 9:00 AM - 11:00 AM
Location: Clinic
Service: Direct ABA Therapy
Provider: Jane Smith, RBT
Supervisor: Dr. Johnson, BCBA

S: Mother reported that J.D. had a difficult morning routine at home and missed breakfast. She mentioned he has been using picture cards at home to request preferred items with prompting. Teacher’s daily note indicated J.D. had a “good day” at school yesterday with one minor tantrum during math.

O: Session focused on communication goals and behavior reduction. During mand training, J.D. independently used picture cards to request preferred items on 7/10 opportunities (70%) and required gestural prompts for 3/10 opportunities (30%). This represents an improvement from 50% independence in previous session. During peer interaction activity, J.D. maintained proximity to peer for 5 minutes and engaged in parallel play with minimal prompting. Shared toy with peer when verbally prompted 2/3 times. One instance of tantrum behavior (crying, falling to floor) occurred during transition from preferred activity (iPad) to table work. Tantrum lasted 3 minutes and resolved with visual schedule implementation and offering choices of work activities. J.D. selected puzzle activity and engaged appropriately for 10 minutes following tantrum. Token economy system was implemented on FR3 schedule for appropriate requesting and transition behavior.

A: J.D. is showing steady progress on mand training goal, increasing independent requesting from 50% to 70% over three sessions. Peer interaction remains challenging but proximity tolerance is improving. Tantrum behavior continues to occur primarily during transitions from preferred to non-preferred activities, but duration has decreased from average of 7 minutes to 3 minutes, and visual schedule appears effective in supporting transitions. Token economy continues to be an effective motivator for appropriate behavior.

P: Will continue mand training with current picture cards and begin introducing 2 new picture cards next session. Will implement 2-minute warning prior to transitions and continue using visual schedule. Will consult with BCBA regarding introducing social skills curriculum to address peer interaction goal more systematically. Will provide parent with visual schedule template for home use during morning routine. Next session scheduled for 10/17/2023.

Key Points to Remember

Session notes should be objective, specific, and measurable
Include information about intervention implementation and client response
Connect observations to treatment goals and progress
Use a consistent format (SOAP, DAP, or narrative)
Document both successes and challenges
Avoid subjective interpretations and judgmental language
Complete documentation promptly and accurately
Maintain confidentiality and professional boundaries
Follow agency and payer requirements for content and format
Session notes serve clinical, communication, and administrative purposes