SAGE Learning Lab

As many healthcare providers accept insurance coverage for ABA therapy, which is typically funded by most insurance companies, there is a growing need for objective documentation that reflects client progress towards treatment goals and identifies barriers to client outcomes. Additionally, session notes help substantiate billing claims, provide a rationale for the need for ongoing services, are included as part of the client’s medical record, and are required by funders to remain in compliance with regulations. However, despite the need for staff training in this area, there have been few studies published in the behavior analytic literature that have evaluated how to write session notes effectively. This course outlines a behavioral skills training (BST) model for training staff on how to write medically necessary session notes and provides a framework for quality assurance measures, to ensure staff document relevant information. Direct training, checklists, templates, rubrics, and evaluation measures are presented, outlining a systematic approach to generating more accurate and objective session notes.