RBT Progress Notes Protocol

RBT Progress Notes Protocol

Definition of Progress Note

A progress note is a medical record that outlines the extent of services provided. Its documentation carries legal, clinical, and ethical implications.

CPT Codes Available for RBT Use

1. 97153 - Behavior treatment by protocol, administered by a technician under the direction of a behavior analyst, face-to-face with one patient, every 15 minutes.
2. 97153 XP - Behavior treatment by protocol under concurrent supervision. Non-reimbursable for Medicaid-funded cases.

Basic Elements of the Progress Note (Required Information)

1. Timely Documentation: The note must be written, created, and signed within 48 hours of service delivery. It is best practice to document immediately after the service is provided. Clearly include the date, time, and duration of services.
2. Participants: Include the names of all individuals involved in the session (e.g., observers, teachers, parents, or other healthcare professionals).
3. Maladaptive Behaviors: Document any behaviors targeted for reduction that were observed during the session. Be specific and include measurable data, such as rate or frequency.

   Example: Record any unusual or significant behaviors observed during the session.

4. Replacement Behaviors: Document all behaviors targeted for increase, such as functional or socially significant behaviors. Include measurable data, such as opportunities to respond, prompts required, or independent initiations.
5. Client Response to Treatment: This is a required element for all behaviors observed and all programs conducted during the session. For each intervention or strategy implemented, document how the client responded to treatment. This includes:
   1. Barriers to treatment progress, if observed
   2. Medication changes, illnesses, or other health-related issues impacting behavior
   3. Environmental changes that may have influenced the session
   4. Effectiveness of reinforcers used, preferred or aversive stimuli observed
   5. Progress on goals addressed during the session

   Example: If the session targeted manding, describe how the client responded to the manding intervention (e.g., increase or decrease in independent requests, level of prompting needed, or any observed improvements).

Topics Not Authorized to Include in Documentation

RBTs must ensure the following activities are not documented in progress notes:

• Indirect Services
  • Time spent writing the progress note
  • Time spent preparing the therapy setting before or after the session
  • Time spent creating therapy materials
• Activities Outside the Scope of ABA
  • Personal care tasks (e.g., toileting, feeding, dressing, bathing)
  • Academic activities (e.g., reading, homework)
  • Pre-employment or work skill training
• Unauthorized Services or Locations
  • Interventions not included in the client's Behavior Support Plan (BSP)
  • Service delivery at locations not specified in the BSP (e.g., providing services at school without prior approval)
  • Non-evidence-based interventions
• Overlapping Services
  • Services delivered concurrently with other providers engaged directly with the client (e.g., occupational therapy, speech therapy, recreational therapy)
• No Direct Engagement
  • If the recipient is sleeping or watching TV
  • Observing the client during leisure or sports activities (e.g., soccer)
  • Transportation/commuting times
• Activities Outside the Scope of RBT Practice
  • Parent training
  • Modifications to treatment plans
  • Documenting personal identifiable information unrelated to treatment implementation

Frequently Asked Questions

1. What Constitutes an Incomplete Record? Incomplete records lack essential elements of documentation. Examples of deficiencies include:

   • Missing signatures
   • Absence of a summary
   • Unclear descriptions of session activities
   • Failing to describe the client's response to treatment
   • Missing the date, time, units, or service location
2. Who Can Request Medicaid-Related Records? Authorized state and federal agencies, under Florida Medicaid Rule 59G-1.054, may audit or examine provider records to determine payment accuracy. Providers must grant access to all Medicaid-related records and supporting documentation.
3. How Long Do I Have to Complete Progress Notes? At the Company, progress notes must be created daily and signed within two business days from the service date.

4. What Are Common Documentation Mistakes?

   • Writing personal perceptions of treatment (e.g., "Client was angry" or "Client does not want to participate")
   • Documenting indirect activities (e.g., material preparation)
   • Delaying completion of progress notes beyond the service date

Helpful Terminology Adjustments

To improve clarity and professionalism in notes, replace vague or subjective descriptions with more precise language:

Examples of progress notes. Direct Therapy Session Note (97153)

Red: EBP Strategy Blue: Behavior (increase/decrease) Green: DSM-5 Deficit Brown: Progress

Example 1

Prior to the session, the RBT asked CLIENT's parents if there were any setting events that might impact his behavior during the session. There were no reported setting events. During the session, the RBT implemented the response interruption and redirection (RIRD) procedure, to redirect repetitive behaviors that interfered with the client playing with toys in the manner in which they were designed, and to remediate deficits related to insistence on sameness. The procedure was effective in increasing the frequency of this behavior during the session, as compared to the data from the previous session (30% increase in appropriate toy play). The client displayed a high rate of vocal protest behaviors during task demands (hypothesized function was escape). The RBT used functional communication training (FCT) and differential reinforcement, to reinforce 2-3 word phrases, to remediate deficits related to back and forth communication. There were fewer prompted mands than in the previous session (25% more independent mands). The RBT used a shaping procedure to reinforce successive approximations for vocal phrases, to increase the intelligibility of the client's requests, to remediate deficits related to responding to social interactions. The level of the successive approximations remains the same as it did from the previous session. The RBT will communicate any barriers to treatment progress to the supervisor and will continue to implement the treatment strategies, as outlined in the behavior intervention plan (BIP).

Red: EBP Strategy Blue: Behavior (increase/decrease) Green: DSM-5 Deficit Brown: Progress

Example 2

Prior to the session, the RBT asked CLIENT's parents if there were any setting events that might impact his behavior during the session. Although there were no setting events reported, the client was observed to lay on the floor frequently throughout the session, yawning, and displayed a higher frequency of vocal protests. During the session, the RBT used antecedent intervention strategies (i.e., wait card), to facilitate back and forth nonverbal exchanges, to remediate deficits related to sharing imaginative play. The client required 30% fewer prompts than the previous session. The RBT utilized visual supports throughout the session (i.e., visual schedule) to decrease instances of elopement during transitions, to remediate deficits related to inflexible adherence to routines and insistence on sameness. There were eight fewer instances of elopement than the previous session. The RBT used DTT strategies and prompting to teach labeling body parts (tact), to remediate deficits related to sharing interest or affect. The client required 10% more vocal prompts than the previous session and the RBT hypothesized that the client's low energy level contributed to the increase in prompts. Finally, the RBT used DTT strategies to work on intraverbal questions regarding personal information, to remediate deficits related to back and forth conversations. There was a noted improvement in this goal as compared to the previous week, demonstrated by 100% correct responses to all questions. The RBT will communicate any barriers to treatment progress to the supervisor and will continue to implement the treatment strategies, as outlined in the BIP.

Red: EBP Strategy Blue: Behavior (increase/decrease) Green: DSM-5 Deficit Brown: Progress

Example 3

Prior to the session, the RBT asked CLIENT's parents if there were any setting events that might impact his behavior during the session. It was reported that the client did not sleep throughout the night (waking often) and had been awake since 5 am. Additionally, the client did not eat breakfast, which was atypical. The client displayed vocal protests and attempts to elope, during the transition into the building. During the session, the RBT used prompting to increase the frequency of the client's approach to others during social exchanges, to remediate deficits related to social approach. The level of prompts required was less from the previous session by 15%. The RBT used a modified extinction procedure during instances of attention-maintained behaviors (squealing) and used prompting to reinforce the client's vocal requests for help, to remediate deficits related to sharing of interests and emotions. There was a 20% increase in this behavior from the previous session, and this was hypothesized to be a result of the multiple setting events reported by the parent. The RBT utilized a shaping procedure to reinforce successive approximations during mand training, to increase the intelligibility of his vocal requests, to remediate deficits related to increasing verbal communication and intelligible speech. The client demonstrated improvements with intelligible speech compared to the previous week with an improvement of 25% intelligibility. Finally, the RBT implemented incidental teaching strategies throughout the session, to reinforce independent responding during play activities, to remediate deficits related to excessively circumscribed or perseverative interests. There was a noted improvement from the previous sessions, with a 12% reduction in prompts required. The RBT will communicate any barriers to treatment progress to the supervisor and will continue to implement the treatment strategies, as outlined in the BIP.

Red: EBP Strategy Blue: Behavior (increase/decrease) Green: DSM-5 Deficit Brown: Progress

Example 4

Prior to the session, the RBT asked CLIENT's parents if there were any setting events that might impact his behavior during the session. There were no reported setting events. During the session, the RBT utilized Pivotal Response Training (PRT) strategies to increase the frequency of eye contact during requesting opportunities, to remediate deficits related to initiating greetings with others. While the client actively engaged with the RBT during these exchanges, there was 15% less eye contact observed than during the previous session. The RBT used a token economy system, to reinforce correct responses during DTT trials, for receptive discrimination targets, and to remediate deficits related to integrating nonverbal communication. The client complied with adult instructions and worked to receive all tokens (without vocal protests), which was an improvement from the previous session where five instances of vocal protest were documented. The RBT used differential reinforcement strategies to increase the quality of the client's open-ended phrases (intraverbal goal), to remediate deficits related to responding to social interactions. The RBT was able to fade the prompt level (full echoic to partial echoic) during this activity, which was an improvement from the previous session. Finally, the RBT used a response interruption and redirection (RIRD) procedure to decrease repetitive actions with play items, to remediate deficits related to motor stereotypes with objects. The client showed a 17% increase in appropriate play exchanges, which was an improvement from the previous session. The RBT will communicate any barriers to treatment progress to the supervisor and will continue to implement the treatment strategies, as outlined in the BIP.

Red: EBP Strategy Blue: Behavior (increase/decrease) Green: DSM-5 Deficit Brown: Progress

Example 5

Prior to the session, the RBT asked CLIENT's parents if there were any setting events that might impact his behavior during the session. While there were no reported setting events, the client was observed to say, "eat" throughout the session and made multiple attempts to access his lunch, which was atypical. The RBT used a token economy system to increase the frequency of responding to instructions during adult-directed structured teaching trials (DTT), to remediate deficits related to pervasive and circumvented interests. The RBT was able to thin the schedule of reinforcement from the previous session from an FR1 to an FR3 which was a noted improvement. The RBT used differential reinforcement to increase the frequency of the client's mands during incidental teaching opportunities, to remediate deficits related to eye contact and body language. There was a 30% increase in the client's eye contact during this activity. The RBT used functional communication training (FCT) to prompt the client to vocally respond to a peer to remediate deficits related to responding to social interactions. The client still requires vocal prompts to respond, which was the same level of progress as the previous session. Throughout the session, the RBT used incidental teaching and pivotal response treatment (PRT) strategies to increase the frequency of the client's spontaneous requests (mands), to remediate deficits related to sharing of interests. The number of spontaneous requests increased by 14% from the previous session. The RBT will communicate any barriers to treatment progress to the supervisor and will continue to implement the treatment strategies, as outlined in the BIP.

Red: EBP Strategy Blue: Behavior (increase/decrease) Green: DSM-5 Deficit Brown: Progress

Example 6

Prior to the session, the RBT asked CLIENT's parents if there were any setting events that might impact his behavior during the session. Parents reported that the client complained of abdominal upset upon waking that morning. It was hypothesized that this could be a possible setting event for the client's lower activity level observed throughout the session. The RBT used visual supports (pacing prompt card) to increase the intelligibility of the client's speech while requesting items, to remediate deficits related to initiating social interactions/including increasing verbal communication and intelligible speech. The client continues to need the visual prompt card to improve the intelligibility of speech and communication. Throughout the session, the RBT used pivotal response treatment (PRT) and incidental teaching to contrive teaching opportunities to increase manding (spontaneous and prompted), to remediate deficits related to sharing of interests. There were 20 fewer mands noted during the session, and it is hypothesized that this is related to the abdominal discomfort setting event. The RBT utilized reinforcement strategies during choice-making routines, to increase the frequency of vocal requests (as opposed to vocal protests), to remediate deficits related to excessively circumscribed and pervasive interests. There were 19 more vocal protests noted during this session, again hypothesized to be affected by the setting event noted above. The RBT will communicate any barriers to treatment progress to the supervisor and will continue to implement the treatment strategies, as outlined in the BIP.