Documentation Do's & Dont's
What does "objective documentation" mean?
What is Writing only what you see and hear, not opinions.
What federal law protects client privacy in healthcare?
What is HIPAA?
What does PHI stand for?
Personal Health Information
You see a data sheet left in the hallway. What should you do?
Secure it and inform the appropriate staff member.
What is the responsibility of all RBTs when it comes to confidentiality?
To protect client information at all times.
True or False: It's okay to copy/paste the same session note for multiple days.
What is false?
What’s one way to protect electronic client data?
Use password-protected or encrypted systems.
Is a client’s favorite color PHI?
No
A coworker shares a funny client quote at lunch. Breach or not?
What is a breach?
Which code section addresses protecting client dignity and privacy?
Section 2 of the BACB Ethics Code.
Give an example of a subjective and an objective note.
“He was mad” vs. “Client screamed and threw pencil.”
Who can you legally share client information with?
Staff with a need to know for treatment purposes.
Are session notes PHI?
Yes
You email a client name to a coworker using a personal email. What’s the issue?
Insecure platform and unauthorized disclosure.
What should you do if you suspect a confidentiality breach?
Report it to a supervisor.
When should you complete your session notes?
As soon as possible after the session. No later then 24 hours after the session
What is a common physical security method for paper data?
Locked cabinets or drawers.
Is a birthdate PHI?
Yes
You're discussing client behavior in the staff room with initials only. Is this safe?
Maybe—only if others nearby have need to know.
Who is responsible for documentation accuracy?
The individual completing the documentation.
What type of language should you avoid in documentation?
Slang, judgmental terms, or emotional language
What is the BACB's primary guidance for confidentiality?
The BACB Ethics Code.
Are general classroom behaviors without names PHI?
No, as long as they’re not identifiable.
A parent asks about another child’s behavior. What should you say?
“I’m sorry, I can’t share information about other clients.”
What is one ethical reason to document objectively?
Ensures accurate treatment decisions and protects client rights.