Domain E Study Guide: Documentation and Reporting

E.1 Communicate Team Concerns & Suggestions with Supervisor

As a trained individual, an RBT must communicate all concerns and avail suggestions from the supervisor or authorized team members.

An RBT's primary role is to report all information objectively. They are not authorized to provide a biased account or a predetermined history.

For instance, the parents of a child under treatment informs the RBT that the child has been waking up from nightmares every night. Here, the RBT must not provide independent suggestions to soothe the child.

Rather, he must relay the new information to the supervisor and await further instructions. Failure to do so may result in suspension.

An RBT also cannot ignore information at will or think of any sudden occurrence as unimportant or invalid. He must record and document every single instance so the supervisor can receive an unbiased account.

E.2 Seek and Prioritize Clinical Direction

Clinical direction refers to approved or authorized medical directions from the supervisor. An RBT must always inform the supervisor when -

• He's unclear about a certain procedure.
• new symptoms or behavior enter the equation.
• there's an unusual behavioral development.
• safety concerns arise.
• the patient demonstrates aggressive and overwhelming behavior.

If the RBT waits too long to inform the supervisor, it may worsen the situation. As such, supervisors should be notified as soon as possible.

E.3 Document Variables That Affect Progress

Variables affect behavioral therapy progress massively. For instance, a subtle change in antecedents can amplify a behavior greatly.

To avoid deteriorating behavioral patterns, RBTs must document variables accurately and inform the supervisor promptly.

Some common variables that affect client progress include - sleeplessness, illness, new medicines, environmental changes, traumatic events, etc.

While reporting, it's also highly important to remain as objective as possible. For instance, a RBT reports 'the patient behaved poorly due to getting less sleep at night'. This is a personal and inappropriate statement.

Rather, the RBT should have reported the factual information directly. Such as - The patient slept for less than two hours last night.

This statement is both fact-driven and objective. RBTs must avoid assumptions and causations to avoid biased stances in reporting.

E.4 Communicate Objective Regarding Session Proceedings

The inherent success of behavioral therapy lies in observable and measurable communication. Every opinion, every statement, and every report must document only facts and discard all forms of personal interpretations.

Here's an example of bad and good language in behavioral therapy:

• "The patient threw a fit." — Unprofessional, biased, and subjective.
• "The patient yelled for 2 minutes and threw three toys at the wall." — Professional, unbiased, and objective.

Through the second statement, the supervisor gets all the relevant information without any unwanted fluff or opinion.

A good session note must include the following components:

• A list of interventions
• Measurable data (behavior frequency, duration, latency, etc.)
• Objective client reaction
• A list of active and inactive variables
• Note of unusual activities or behavioral patterns

Here's a demonstration of a poor vs. good documentation side-by-side:

The poor version includes unnecessary personal opinion and highly lacks objective data. Alternatively, the good version includes objective and measurable data that the supervisor can use to design treatment plans.