E Documentation and Reporting This training program is

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E. Documentation and Reporting This training program is based on the Registered Behavior Technician

E. Documentation and Reporting This training program is based on the Registered Behavior Technician Task List and is designed to meet the 40 hour training requirement for the RBT credential. The program is offered independent of the BACB.

E -01 Client Variables Session notes are a permanent record of how each therapy

E -01 Client Variables Session notes are a permanent record of how each therapy session goes and should include variables that are reported by parents or can be seen by the behavior technician that may be affecting the client. These variables may include: • Illness – This could be short or long term and may affect shortening or cancelling a session. (Please follow the guidelines in the Employee Handbook concerning cancellations. ) www. cap-autism. com

E -01 Client Variables • Medications – Note any medication changes reported by parents

E -01 Client Variables • Medications – Note any medication changes reported by parents in the session notes. (You will not be administering medications. ) • Sleep – Many clients will have atypical sleeping patterns and the RBT should note any sleep issues reported by the parents, or instances of the child falling asleep during sessions. www. cap-autism. com

E -01 Client Variables • Relocation – changing living conditions should be noted in

E -01 Client Variables • Relocation – changing living conditions should be noted in session notes including moving temporarily or permanently. • Mental health – many clients may be diagnosed with, or be at risk for, a co-morbid mental health condition. Behavioral symptoms may be noted in session notes, though no suggestion or inference of a condition may be made. www. cap-autism. com

E -01 Client Variables Siblings – May be present during sessions or want to

E -01 Client Variables Siblings – May be present during sessions or want to play with the technician. If there is not a plan in place to include siblings the technicians will politely remove siblings from therapy area. Problems and questions concerning siblings should be addressed to the supervisor. Other – any other variables affecting the client should be noted and reported to the supervisor. www. cap-autism. com

E-02 Session Notes A session note should include: • Only objective information • Only

E-02 Session Notes A session note should include: • Only objective information • Only behavioral information • Describe behaviors observed www. cap-autism. com

E-02 Session Notes Session notes should not contain: • Subjective descriptions or explanations •

E-02 Session Notes Session notes should not contain: • Subjective descriptions or explanations • Suggestions for changes or comments on behavior • Notes to co-workers • Personal notes www. cap-autism. com

E-02 Session Notes Acceptable session note example: Johnny came to the table without prompting

E-02 Session Notes Acceptable session note example: Johnny came to the table without prompting today. He completed 95% of the programs without maladaptive behaviors, though he did swipe cards off the table one time. He mastered the acquisition item in the categories program today. He responded well to bubbles and the wind-up toy but not the cookies or balloon. He played with his dinosaurs and cars today. He laughed and requested “tickles” verbally many times. His mother reported that he did not wake up during the night last night. www. cap-autism. com

E-02 Session Notes Unacceptable session note example: Johnny was a delight today. He loved

E-02 Session Notes Unacceptable session note example: Johnny was a delight today. He loved coming to the table to work, though he did get angry with the cards one time and was awful. He is ready for the next item in categories, so hopefully Megan will have those ready for us tomorrow. He loves his bubbles still, and the wind-up toy but I think he is bored with the cookies and balloons. He liked playing with his cars and was so cute making the dinosaurs fight and then go to sleep. I could get him to ask for “tickles” today and he just loved them. Mom said he finally slept through the night which is probably why he wasn’t such a bear today. www. cap-autism. com

E-03 Communicate with Supervisor The supervisor should always be the main point of contact

E-03 Communicate with Supervisor The supervisor should always be the main point of contact for all clinical matters involving the client. The supervisors has the most thorough perspective of ABA knowledge, client needs and technician skill. Timely responses and initiations with supervisors are essential. Communicating with co-workers or parents instead of the supervisor can lead to miscommunication, drama and reduced effectiveness. www. cap-autism. com

E-03 Communicate with Supervisor The technician must communicate through written and oral means accurately

E-03 Communicate with Supervisor The technician must communicate through written and oral means accurately and appropriately with the supervisor via email, phone, text or in person. The same parameters that apply to session notes, apply to communication with the supervisor. Feedback from the supervisor will be ongoing as part of the 5% supervision requirement. www. cap-autism. com

E-03 Communicate with Supervisor As part of supervision, the technician should make use of

E-03 Communicate with Supervisor As part of supervision, the technician should make use of other learning opportunities which may be provided by the supervisor, such as literature and journal articles on specific topics. The technician is responsible for being aware of their own skill set and areas of needed improvement. These can be discussed during supervision. www. cap-autism. com

Legal Implications and Reporting • We are bound by HIPAA laws that prevent us

Legal Implications and Reporting • We are bound by HIPAA laws that prevent us from divulging privileged confidential information without written consent. There are certain circumstances in which we must breech this confidentiality. Circumstances such as: – – • • Neglect Abuse When a client is in imminent danger or harming themselves or others Elder abuse We are mandated reporters! All individuals working with individuals with disabilities are considered mandated reporters. Suspected abuse or abuse must be reported immediately to the abuse authorities and your supervisor. After abuse or any of the above are reported – Continue to provide services without acting different – Maintain confidentiality at all times www. cap-autism. com

E-04 Mandatory Reporting www. dss. virginia. gov/family/cps/mandated_rep orters/cws 5692/index. htm Please complete this online

E-04 Mandatory Reporting www. dss. virginia. gov/family/cps/mandated_rep orters/cws 5692/index. htm Please complete this online training before continuing. Any concerns involving mandatory reporting must be discussed with your supervisor. www. cap-autism. com

E-05 Data Collection, Storage and Transportation Because behavior technicians at Comprehensive Autism Partnership, Inc.

E-05 Data Collection, Storage and Transportation Because behavior technicians at Comprehensive Autism Partnership, Inc. generally work in-home, data collection and storage are contained within the client home. At present we do not use electronic communication of these client records by the behavior technician, but it is important to know that client records are governed by the Health Information Portability and Accountability Act (HIPAA). www. cap-autism. com

HIPAA www. youtube. com/watch? v=zj_jrj 5 s. D 7 o Please watch this video

HIPAA www. youtube. com/watch? v=zj_jrj 5 s. D 7 o Please watch this video before continuing. www. cap-autism. com

HIPAA As a behavior technician you will not generally come in contact with Personal

HIPAA As a behavior technician you will not generally come in contact with Personal Health Information (PHI) except that which is in the client’s home. There are few instances where you may, such as: • Taking a data binder home to update it • Printing extra session notes which contain the client’s name • Carry an electronic or paper calendar with client names, addresses and phone numbers. • Emails to supervisors which contain client names. www. cap-autism. com

HIPAA Do not take client records from the client home without specific permission from

HIPAA Do not take client records from the client home without specific permission from your supervisor. Make sure to keep any such records securely in your possession and never take them anywhere they could be left, forgotten, or seen by others. Check with your supervisor if you have any concerns about data privacy. www. cap-autism. com

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