Writing session notes

What a session note has to carry

A session note is a clinical record and usually a billing record at the same time, which is why a thin one causes trouble twice: it leaves the next person without the context to continue, and it leaves a funder able to claw back payment for a session that genuinely happened. Most of what makes a note defensible is not effort, it is coverage — the same handful of elements, every time, written close enough to the session that you still remember it. This list is the common core. It is not your employer's template, and where the two differ, the template wins.

Your employer, your funder and your state set the actual requirements, and they differ. Use your organisation's template and ask your supervisor what your funders expect. This app cannot know any of that, so treat the list as a prompt rather than as a standard.

0 of 9 ticked. This is scratch paper — nothing here is saved, on purpose.

Who, when and where — by code, not by name
Every note needs to be attributable to a session: the client identifier your organisation uses, the date, the start and end times, the setting, and who was present by role. Times matter because they are what a funder checks against the claim, and a note whose times do not match the billed units is the single most common audit finding.

Like this Home, 3:05 to 5:05 pm, caregiver present for the last 20 minutes.
Who delivered the service, and their credential
The record has to show that the person delivering the service was qualified to and, for a technician, that they were working under supervision. Sign it yourself and do not sign for anybody else.
The programs or goals you actually ran
Name them the way the behaviour plan names them, so the note lines up with the plan a supervisor or auditor will read beside it. If a planned program did not run, say so and say why, rather than leaving a silence that reads as an omission.

Like this Ran the tacting program and the two mand targets; did not run the toileting program because the session was at school.
What the data showed
A number without a measure is not data. Say what was counted or timed, and over what period, so the figure can be compared with the one before it. The note does not need the whole data sheet; it needs enough for a reader to know whether the session was typical.

Like this 14 independent mands across the session, up from 9 in the last session; prompted trials fell from 11 to 6.
How the learner responded, described rather than judged
This is where notes usually go wrong. Describe what you saw and heard in terms somebody else could have counted, not how it felt. Interpretation belongs in the supervisor's analysis, and a note full of it is hard to defend later.

Like this Pushed the materials away twice and left the table for about 40 seconds each time, returning without a prompt.
Anything unusual, and anything that changed
A missed medication, a new person in the house, a schedule change, an illness, a first occurrence of a behaviour — these are the things that explain a data point three weeks from now. They are also the things nobody remembers by the next morning.
Injuries and incidents, and the separate report they trigger
Any injury to the learner, to you or to anybody else goes in the note and also into whatever incident process your organisation runs, the same day. The two are not interchangeable, and a note that mentions an injury with no matching report is a gap somebody will ask about.
What you handed to the next session
One line on what you would do differently or what the next person should watch for. It costs nothing and it is the part of a note colleagues actually read.

Like this Break card was used four times in the second hour; worth checking whether the demand density is too high late in the session.
Written and submitted inside your organisation's window
Both codes treat timeliness as an obligation rather than a preference, and memory for detail is mostly gone within a day. A late note is also a late claim, which can cost the client their authorisation rather than costing you anything.

Saying it so somebody else could have counted it

Most weak documentation is not careless, it is compressed. Writing that a session went badly is a summary of everything you noticed, and by the next morning it is the only thing left. The fix is a habit rather than a vocabulary: before writing a word about behaviour, ask whether a second person watching the same session would have written the same thing. If they might not, the sentence is carrying your interpretation, and the interpretation is the part your supervisor needs to make rather than inherit. Objective language is also what makes a record defensible — it is much harder to argue with a count and a duration than with an adjective.

Your supervisor decides what a behaviour means and what to do about it. Your job in the note is to describe it accurately enough that they can. Where your organisation has its own wording conventions, follow those.

Instead of He had a rough day.

Write Left the work area 7 times in a 2-hour session, compared with 2 and 3 times in the previous two sessions. Each absence lasted under a minute.

Rough is a judgement about the whole session. A count and a comparison say what changed and let a supervisor see a trend rather than a mood.
Instead of She was being manipulative to get out of work.

Write Said she needed the bathroom at the start of 4 of 6 work blocks, and returned within a minute each time without using it.

Manipulative attributes a motive. The description carries the same information about a possible escape function without the app or the writer deciding the function.
Instead of Refused to comply.

Write Did not begin the task within 10 seconds of the instruction on 8 of 12 trials, and began within 10 seconds after one repeat of the instruction on 5 of those.

Refused hides both the measure and the response to prompting, which is usually the part that matters for the next session.
Instead of Was aggressive towards staff.

Write Hit the table with an open hand 3 times and pushed a chair over. No contact with staff, no injuries.

Aggressive covers everything from a raised voice to an injury. Naming the topography and stating whether anybody was hurt is what an incident review will ask for anyway.
Instead of Had a tantrum for ages.

Write Cried and lay on the floor for about 6 minutes, timed from the instruction to the first response to a prompt.

Tantrum is a label for a set of behaviours, and for ages is not a duration. Timing one episode is more useful than characterising a hundred.
Instead of Great session, he did really well.

Write 11 of 14 targets independent, up from 8 last session. Accepted the transition to the table on the first instruction both times.

A compliment is not a record. The same sentiment with numbers tells the next reader what to keep doing.
Instead of Seemed tired and unmotivated.

Write Yawned repeatedly, put his head on the table 4 times, and worked for preferred items he selected without hesitation the previous session but declined twice today.

Tired is an inference about an internal state. What you actually observed is behaviour, and the change in what worked as a reinforcer is the clinically useful bit.
Instead of Attention-seeking behaviour throughout.

Write Called out to the therapist 15 times during independent work. Each instance was followed by a look and a brief response from an adult in the room.

Naming a function in a note states a conclusion that comes from an assessment. The count and what followed it are the evidence for it, which is what your supervisor wants.
Instead of Doing it for sensory reasons.

Write Rocked and hummed for roughly 3 minutes at a time, in 5 episodes, all of them when no task was in front of him and no adult was interacting with him.

Sensory is a guess at a maintaining variable dressed as an observation. Describing when it happened and what was going on is a technician's proper contribution.
Instead of Mum was uncooperative.

Write The caregiver said she had not been able to run the evening programme this week and asked whether it could be shortened.

Uncooperative is a characterisation of a person, and it will read badly to everybody who sees the record later, including that person. What was said is both fairer and more useful.
Instead of He is nonverbal.

Write Communicated using a speech-generating device and by leading an adult by the hand. No vocal words observed this session.

Nonverbal describes a person rather than an observation, and it is often inaccurate. Naming the modality respects how the person actually communicates.
Instead of Behaviour was better today.

Write 2 instances of the target behaviour, against a running average of 6 over the last five sessions.

Better than what is the question the sentence leaves open. A comparison answers it and makes the note worth reading beside a graph.
Instead of Tried really hard.

Write Stayed at the table for both 20-minute blocks and requested a break twice using the break card rather than leaving.

Effort is not observable. Using the replacement behaviour instead of the old one is, and it is the thing the plan is trying to teach.
Instead of No problems.

Write No instances of the target behaviour. Ran all four programmes as written.

No problems could mean a good session or a session where nothing was run. Saying which protects you.

Never put a client's name, initials, date of birth or address into an example, a search, or anything else in this app. The examples above are invented.