Guidelines for Effective Documentation for RBTs Flashcards
Documentation
A written form of communication with the purpose of ensuring that events that take place are properly recorded
Variables that affect clients
Noticeable changes or issues with clients that affect treatment and need to be reported
Frequency
An indication of how many times a behavior or event occurs
Duration
An indication of how long a behavior lasts
Interval recording
Used to record whether a behavior occurs during a particular interval
A-B-C recording
Writing down an antecedent (or what happened before a behavior occurred), the behavior, and the consequence (or what happened after the behavior occurred)
Anecdotal recording
Writing down everything that happened
Session notes
Documentation of what happened during the session
Incident reports
Documentation of unusual events that occur during service provision, which are called incidents
PHI
Protected health information, which is any health information that can be used to identify a patient or client
e-PHI
Protected health information in an electronic form
Minimum necessary rule
Information about clients that can be shared only to the extent that it accomplishes the goal
Observable and measurable language
Descriptions of what can be seen, heard, felt, or counted