Objective Vs Subjective
Is this objective or subjective? “Client had a great day and was very happy.”
Subjective
“Client had a really good session and did great with programs.”
“Client independently completed 8 of 10 targeted matching trials and required verbal prompts for 2 trials.”
When should a session note be submitted?
Within 24 hours of the session.
Provide an example one success that should be documented.
Examples: independent communication, successful transition, correct program response, increased independence, or appropriate social interaction.
Which is better? A: “Worked on communication.” B: “Client independently requested ‘more bubbles’ 4 times.”
B
Is this objective or subjective? “Client independently requested bubbles 5 times.”
Objective
“Client was being difficult and refused to work.”
Example: “Client pushed the worksheet away and left the table twice following presentation of the task.”
True or False: A BT can wait several days because they remember the session.
What should be documented when challenging behavior occurs?
Observable behavior plus relevant context, staff response, prompting/intervention, and outcome; include frequency/duration when available.
What three questions should guide your session note?
What did the client do? What did I do? What happened next?
Correct this: “Client was being difficult during work.”
“When presented with a matching task, client pushed materials away and left the table twice.”
"Client got upset when it was time to clean up.”
Example: “Following the clean-up instruction, client yelled and dropped to the floor for approximately 30 seconds. BT provided a verbal prompt and modeled placing items in the bin. Client then picked up 4 items.”
Why is timely documentation important?
It keeps the clinical record current and improves accuracy of the information available to the treatment team.
Name two things you could document under Play/Social.
Examples: functional play, peer interaction, turn taking, sharing, social communication, or prompting needed.
Why should prompting be included in the note?
It helps communicate the level of assistance needed and the client’s independence.
Correct this: “Client did not want to participate.”
Example: “When presented with the activity, client turned away, pushed materials away, and left the area.”
“Client played nicely with peers.”
Example: “Client played a car game with two peers for approximately 10 minutes and exchanged cars with peers twice.”
You realize your note from yesterday was not submitted. What should you do?
Complete and submit it as soon as possible
What are examples of ADLs that may be relevant to a session note?
Toileting, handwashing, eating, dressing, hygiene, and other daily living skills addressed during session.
Which is more useful: “Client struggled with matching” or “Client independently matched 7/10 cards and required model prompts for 3”?
The second statement.
Name three things that make documentation objective.
Observable behavior, measurable information, and specific actions/outcomes.
“Client did not want to do ADLs but eventually did them.”
Example: “During handwashing, client required one verbal prompt to apply soap and independently completed the remaining steps.”
True or False: A detailed note submitted late meets the documentation expectation.
False
Why should a note include more than just challenging behavior?
The note should provide an accurate picture of the session, including successes, skill acquisition, social/play participation, ADLs, and behavior when relevant.
What makes a session note clinically useful to another team member who was not present?
Specific observable details, relevant data, programs/skills addressed, prompting/interventions, challenging behavior when applicable, and client outcomes.