Session Note
Also called: progress note, daily note, service note
Definition
The record of a service delivered, written to document what occurred for clinical continuity, supervision, and billing. Required elements are set by the payer, the employer, and applicable regulation, and typically include service times, what was worked on, objective observations, and the writer's credential and signature.
In plain language
The record you write after a session. It says what you did and what you saw. What must be in it is set by your employer and whoever pays for the service.
Examples
A note recording exact start and end times, the goals worked on, data collected, and an objective description of what happened.
A description written as what was observed rather than what the writer concluded from it.
Not session note
A note saying the session went well with no detail about what was done or observed.
A note recording a conclusion about why a behavior happened, which is interpretation rather than observation and is not the technician's to make.
Commonly confused with
See also
Written from
- bacb-rbt-ethics-code-2 — Documentation and reporting responsibilities
Written from the documentation responsibilities described in the technician ethics code, and from general audit and payer requirements. No code text reproduced.
This entry has not yet been through clinical review. Treat it as a draft.