Guidelines for Effective Documentation for RBTs Flashcards

1
Q

Documentation

A

A written form of communication with the purpose of ensuring that events that take place are properly recorded

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2
Q

Variables that affect clients

A

Noticeable changes or issues with clients that affect treatment and need to be reported

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3
Q

Frequency

A

An indication of how many times a behavior or event occurs

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4
Q

Duration

A

An indication of how long a behavior lasts

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5
Q

Interval recording

A

Used to record whether a behavior occurs during a particular interval

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6
Q

A-B-C recording

A

Writing down an antecedent (or what happened before a behavior occurred), the behavior, and the consequence (or what happened after the behavior occurred)

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7
Q

Anecdotal recording

A

Writing down everything that happened

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8
Q

Session notes

A

Documentation of what happened during the session

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9
Q

Incident reports

A

Documentation of unusual events that occur during service provision, which are called incidents

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10
Q

PHI

A

Protected health information, which is any health information that can be used to identify a patient or client

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11
Q

e-PHI

A

Protected health information in an electronic form

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12
Q

Minimum necessary rule

A

Information about clients that can be shared only to the extent that it accomplishes the goal

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13
Q

Observable and measurable language

A

Descriptions of what can be seen, heard, felt, or counted

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