Writing it down honestly
Notes and data are clinical, legal and billing records at once
- RBT
- BCaBA
- BCBA
What the obligation is
What you write is used to make clinical decisions, to justify payment, and sometimes in legal proceedings. All three uses require the same thing: that it describes what actually happened, in observable terms, recorded close to the event. Estimating data from memory, filling a gap with last session's numbers, recording scheduled time rather than delivered time, or writing a note before the session are all falsification, whether or not anyone intended fraud. Gaps and errors are normal; the honest handling of them is to mark the gap, say what happened, and tell your supervisor. That is a small conversation. The alternative is an integrity finding, which is not.
In plain language
Write what actually happened, as you saw it, soon after. Record the time you really delivered. If data are missing, say so rather than filling them in.
What this looks like
- Notes completed the same day, in observable language, with times and counts.
- A visible, explained gap where recording failed.
- Session time recorded as delivered, even when the family ended early.
- Telling your supervisor about an error before anyone else finds it.
Where people get caught
- Reconstructing numbers from memory, which looks identical to real data on a graph.
- Writing interpretations or motives instead of observations.
- Billing the scheduled duration rather than the delivered one.
- Leaving a gap blank and unexplained, so it reads as zero occurrences.
If you are not sure
Write only what you can stand behind, note what is uncertain, and ask your supervisor how they want the gap recorded. Never resolve uncertainty by guessing a number.
In the codes
- RBT Ethics Code (2.0) Section 2 — How you deliver services
- 2.02 Follow the plan, and record what actually happened
- RBT Ethics Code (2.0) Section 3 — What you owe the board and your supervisor
- 3.02 Be accurate with the board and with your supervisor
- Ethics Code for Behavior Analysts Section 2 — Your conduct in practice
- 2.06 Bill and report accurately
- 2.07 Handle fees honestly
- Ethics Code for Behavior Analysts Section 3 — What you owe clients and stakeholders
- 3.11 Document your professional activity properly
On the exam
Terms used here
Situations where this comes up
Related topics
Written from
- bacb-rbt-ethics-code-2 — Accurate documentation and billing
- bacb-ethics-code-2022 — Documentation and billing standards
- peterson-homer-wonderlich-1982
Written from both codes' documentation and billing standards and the treatment-integrity literature, in our own words.
This entry has not yet been through independent review. Treat it as a draft, and read the official code for anything that matters.