SOAP Notes
What is the deadline for submitting SOAP notes?
SAME DAY (before you leave the center)
Scenario: One of my CR sessions has the wrong client's name on it. What should I do?
Step 1: Don't convert it
Step 2: Send a message to our Digital Whiteboard
(ex: my 12-3PM CR for 6/1 needs to be updated. I had SabFa not SadFa)
Scenario: My client is very capable of playing independently in the gym. Can I sit down and talk to my coworker for a bit? My client is playing on the swings, while I am sitting on the crash pad. I have my eyes on him, though, so all should be good.
Therapists must remain focused on and within arm’s length of their clients at all times. Pairing, NET, and social goals should still be run even when the client is in the gym
Where should personal medication be stored?
At home or safely in a personal cubby in the staff lounge
What is the minimum number of data points I should be collecting per hour per session? Is there an exception to this rule?
20/hour/session
True or False: I can reuse my old note from yesterday's session. It's the same client, and we worked on mostly the same programs
False!
Scenario: The daily schedule says that my client got picked up at 3:02 PM, but my CR says 12:00 -3:00 PM. What should I do?
Step 1: Don't convert it
Step 2: Send a message to our Digital Whiteboard
(ex: 6/1 CR with MiHu 12:00-3:02PM)
Scenario: my client is eating a peanut butter sandwich. What is the protocol following that?
Explain protocol
How can a BT/RBT prepare themselves for a session?
True or False: This is my first time working with this client, and I know nothing about them or their programs. This means that I am allowed to collect zero to minimal data
False!
No. Therapists must receive explicit BCBA approval before using edible reinforcement during any session. Edible reinforcers may only be implemented after a signed parent consent form has been obtained and uploaded to Ensora.
Scenario: I am unable to convert my CR session. It says "withheld". What should I do?
Send a message to our Digital Whiteboard
(ex: my 9AM-12PM CR from 6/1 won't convert. It says withheld)
Scenario: my client was playing with sand, and now there is sand everywhere, but my client is ready to leave the area. What should I do?
Ask for staff on indirect to cover your client while you clean-up. Or ask a staff on indirect to help by cleaning up
(free answer)
Scenario: At the beginning of the session, the BCBA told me they opened new targets for my client, but I couldn't find them. What should I do?
Delete the client from your client list on Ensora > completely close the Ensora app > reopen the Ensora app> re-add your client
True or False: For a behavior interventions, I can try and document whichever intervention I think is right, based on my experience with my other clients.
Explain reasoning
False!
What is the deadline to convert all my CR sessions for the day? And what is the only exception to that rule?
11:59 PM that same day.
Exception: incorrect or withheld CR sessions (must send a message to our DW space as your 'excuse')
What is your responsibility if you are on indirect?
(answers may vary)
What is our attendance policy? What is your expectation if you're calling out for the day?
Explain:
- messaging EL Attendance Number
- the point system
- excuse documentation system
How do I obtain 'Raw Data' and why is it important in some cases?
Walk through the steps (Trial sheets/ scroll screenshot/ check box in AI-drafter/ copy+paste raw data under narrative)
Important: in case your data does not sync for any reason (your data shows up as 0)
Scenario: I received a compliance email flagging one of my notes. What should I do?
Fix it ASAP! Or reach out to Malak for help.
Scenario: I see a PTO session added to my CR after I requested it. Who should convert it and when?
The therapist should! You can typically convert CR sessions after the session time has ended (ie.: you can convert a 12-3PM CR session after 3PM that day)
My coworker asked me to watch their client, and I agreed. My client eloped to a different area (the clients are now on opposite ends of the center). What should I do?
1. What is the new checkout system?
2. Does it affect everyone or just some RBTs?
3. Is it a temporary requirement or a daily one, moving forward?
1. New SOAP note check out requirement = every therapist MUST check out with Malak (or a member of the leadership team) before leaving the center to ensure all SOAP notes are submitted for the day.
2. EVERYONE. No exceptions.
3. This is the new daily norm :)
I don’t typically sync my data, and I haven’t received any SOAP note flags so far. Is it acceptable for me to continue not using the sync function?
No! Everyone must always sync their data before publishing their notes