ABA Session Notes: Components, Examples, Templates and Expert Tips

February 13, 2024

ABA Session Notes: Components, Examples, Templates and Expert Tips

Author:

Thomas John, CEO of Artemis ABA

Documenting patient progress is fundamental to ABA. Learn how to write session notes, explore examples, and download free templates. Get expert tips on how to write effective notes that will meet both clinical and insurance needs.

Inside this article:

The differences between ABA session notes and ABA SOAP notes
The main components of ABA session notes
How to meet ABA session note insurance requirements
Expert tips for writing ABA session notes
How to use technology to help write ABA session notes

What are ABA Session Notes?

ABA session notes are detailed forms describing what happened during an ABA therapy session. The provider writes the notes with basic patient information and a narrative summary of the treatment. The notes also describe behavior targets, intervention types, and data.

April Torres, M.Ed., BCBA., describes session notes as an objective summary of a session. “Session notes describe what the session looked like from a non-clinical point of view. If someone reads your session notes, they should be able to get a glimpse of what the session looked like, even if they’re not trained in ABA.”

Session notes are the backbone of medical documentation in Applied Behavioral Analysis. ABA clinicians rely on them to track and assess a patient's response to skill acquisition programs and ABA behavior intervention plans. These notes offer insights to behavior analysts and other stakeholders and help ABA professionals monitor patient progress and refine their strategies based on the most up-to-date information.

Also, session notes are key for insurance claims validation. Payors request session notes to confirm that the provider performed the services on a claim and that the intervention was medically necessary and relevant. The bottom line is that payors look to session notes to help substantiate the medical need for ABA treatments.

In a 2021 paper published in the Journal of Behavioral Analysis, the authors discuss how higher demand for ABA services has increased the number of insurance companies covering behavior analysis services.

The authors write, “The increase in funding by insurance companies is paired with an increase in documentation requirements that can serve as a record of a billed session, substantiate the need for therapy, outline response to treatment, document coordination of care, and note other pertinent events. Session notes are one example of clinical documentation commonly required by insurance companies.”

The paper, titled “The Use of a Brief Treatment Package to Increase Session Note Completion in an ABA Agency,” observes that session notes lack a common standard despite their importance.

The authors go on to describe how session note templates and checklists could help ABA professionals take comprehensive session notes that meet payor guidelines.

Overall, session notes are incredibly important for both clinical and compliance reasons. As demand for ABA continues to grow, there is a growing recognition that the field will benefit from standardized session notes that fulfill all payor requirements and capture all the important clinical information that other medical and behavioral professionals might need. Understanding how to read and write these notes is essential for ABA practitioners.

Key Takeaways:

Session notes are the primary form of medical documentation in ABA.
All insurance payors require that you submit session notes as part of a pre-payment audit.
Session notes contain only objective data, unlike SOAP notes, which also have subjective observations.
Clinicians use session notes to track patients' progress and tailor their treatment.
The best practice management software includes session note templates that help ABA clinicians fulfill payor requirements.

ABA Session Notes Vs. ABA SOAP Notes

ABA session notes differ from SOAP notes in both their content and approach. SOAP notes include both subjective and objective insights and recommendations. Meanwhile, session notes objectively focus on the session’s treatment, goals, and results. Both are essential client records in ABA.

SOAP notes are a standardized method for recording clinical sessions that many medical professionals use. The acronym “SOAP” delineates the four key sections of these notes: Subjective, Objective, Assessment, and Plan. In the context of ABA, both SOAP notes and session notes play an important role in comprehensive client records. However, they fulfill distinct roles and document different facets of a therapy session.

“In BCBA, we use SOAP notes and session notes to target different goals,” explains Torres. “Most use SOAP notes when they’re meeting regularly with a patient to target a very specific issue. These notes blend subjective client observations and objective information and include recommendations for future interventions to help the patient progress on their specific goal. BCBAs and their colleagues usually read these narrative notes to understand session nuances and plan future goals."

Torres continues, "On the other hand, session notes contain objective descriptions about what happened during the session. They're accessible to a broader audience, ranging from insurance payors to the child's teacher. The focus is on what happened in the session and doesn’t include information on subjective recommendations or opinions from the BCBA or RBT."

Torres illustrates one key difference between session notes and SOAP notes with an example: "In a SOAP note, you might start with subjective observations that the ABA practitioner writing the notes feels is relevant, such as 'The patient seemed happy.' However, this type of opinion-based language is not suitable for a session note. Instead, a session note would clearly identify the goal and summarize intervention data, like 'The client smiled and laughed when he greeted the therapist. The client was given ten opportunities to execute a target and responded correctly 70% of the time.’ "

Main Components of ABA Session Notes

The main components of ABA session notes include basic details about the client, the provider, and the session. The core of these notes is a narrative summary. This part outlines interventions, data, and other information that explains what happened during the session.

ABA session notes contain clinical and non-clinical components. While requirements vary among insurance providers, clinical categories typically include a basic summary and detailed descriptions of interventions. Alongside these clinical details, most insurers require basic information like the client’s name, the appointment date, the length of the session, and data about the provider and any other session participants.

Example of ABA Session Notes

Download our free ABA session notes templates

Here’s a summary of the main categories of ABA session notes, with examples. This list includes all the requirements from most major ABA insurance payors. However, it's important to note that this list is not exhaustive, as payors may have different requirements that are subject to change.

Client Information

Patient first and last name:
Example: Emily Thompson
Date of birth: Include the patient's date of birth in the mm/dd/yyyy format.
Example: 03/12/2024
Summary of patient’s current clinical status: Use an ICD (International Classification of Diseases) code to summarize the client’s condition
Example: F84.0 (Autistic disorder)
Insurance: Name the patient’s insurance company.
Example: Aetna

Appointment Details

Date of session (appointment date):
Example: January 25, 2024
Length of session with the start and end time:
Example:
- Start time: 2:00 PM
- End time: 3:30 PM
- Length of session: 90 minutes
Units of service: In ABA, we describe "service" in 15-minute units. A typical 30-minute session would constitute "two" units of service.
Example: Six units of service (A 90-minute session)
Place of service: Write down where the session occurred. Examples include a home, clinic, daycare, school, or telemedicine.
Example: ABC Therapy Clinic

Provider Information

Rendering provider's full name and credentials: Include the name and credentials of the provider who was working with the child in the session.
Example: Samantha Watkins, RBT
Full name and credentials of authorized ABA supervisor (if different than the rendering provider): Include the name of the rendering provider's supervisor, even if they did not attend the session.
Example: Patricia Smith, BCBA-D
Session Participants:
Include the name of anyone who was present for the full session, and their relationship to the child.
Example: Suzy Perkins, Clinic Director

Treatment and Session Details

These sections describe the specific events of the session and end in a narrative summary that the rendering provider writes.

Service rendered: Write the CPT (current procedural terminology) code here. The CPT code is a five-digit code that identifies a specific treatment.
Example: 97153 (Adaptive behavior treatment procedures)
Current clinical status:
Include objective observations of the patient’s behavior when entering the session location and at the beginning of the session. Include your assessment as to whether the patient was ready to engage in the session.

Example: Upon entering the therapy room, Emily made direct eye contact and offered a polite greeting. She seated herself comfortably and appeared ready to engage, indicating a willingness to participate in the session's activities. Initial observations suggest a positive engagement level and readiness to engage in the session.
Treatment interventions:
This section lists your specific ABA techniques, like discrete trial training (DTT), prompting, etc. Some ABA professionals list them, and others mark the interventions they used from a list of options on the session notes template.

Example: Antecedent intervention, extinction, prompt fading, reinforcement.
Response to Treatment:
Report on the patient's response to treatment during the session as related to the treatment plan goals. Include any relevant data summaries.

Example: In this session, Emily Thompson showed significant progress, achieving an 80% success rate in initiating conversations with peers, improving from 60% in the previous session. She excelled in starting interactions, meeting one of her main therapeutic goals. She was still challenged in sustaining conversations for longer than a few minutes.
Progress Toward Goal:
Example: Emily engaged successfully in two social interactions, showing no signs of her previous avoidance behaviors. This improvement represents a 20% decrease in avoidance compared to the previous session, highlighting significant progress due to the antecedent intervention strategies applied.
Session Summary:
Write a few sentences providing an overview of the therapy session. The length of the session summary should correspond to the duration and complexity of the session. Also, RBT session notes capture direct therapy observations and client interactions, whereas BCBA session notes might offer more in-depth analysis, planning, and clinical insights. The session summary should describe the treatment and include activities that align with the CPT code under the "Service Rendered" section.

The ABA session summary should include these aspects:
- A description of the target goal
- A summary of the services the ABA professional provided (these should support the CPT code under the "Services Rendered" section)
- Documentation of the patient's progress and notes on any emerging behaviors or issues
- Any interactions with other people present in the session
- A summary of any relevant ABA data collection
- If applicable, document any referrals to another provider or agency
Dated signature:
Every session note must end with the therapist's signature and the date they wrote it. This date might differ from the service date. The session note should clearly show both dates in their appropriate fields: the date of the service and the date of writing the note.

Why ABA Session Notes Are Important

Session notes are important for many reasons. They substantiate billing claims and justify the need for services from payors. They’re crucial for BCBAs to document and monitor the patient’s progress. Session notes help ABA professionals communicate with others, like doctors and teachers.

Taking notes is critical in all medical professions, and ABA is no exception. These notes represent the provider’s summary of what happened during the session, how that relates to the patient’s ongoing progress, and what might happen next. The notes are the only way to document and track the patient’s progress accurately. They’re of interest to anyone involved in the patient’s care—including parents, other medical professionals, and insurance payors.

Here’s a summary of the main reasons why ABA session notes are important:

Coordination of care
Session notes describe what happened that day in a way that anyone can read and understand. They're helpful when multiple professionals, like teachers or doctors, collaborate with the BCBA to help the child. These notes ensure all individuals are informed about the child's behavioral developments.
Part of medical record
"Session notes form a large part of a patient's medical record," says Torres. "If they move out of state or pursue a different kind of service locally, they can take their session notes to their next provider. This process gives the new provider a comprehensive history and helps them make more informed treatment decisions."
Inform treatment and help catch errors
According to Torres, BCBAs will review session notes to stay current on their patient's care and determine the next steps in treatment. “Session notes are particularly valuable in cases where multiple people are involved in child's care," she adds. "Combined with SOAP notes, they offer a complete view of the child's progress and help us make informed decisions."
Part of medical record
"Session notes form a large part of a patient's medical record," says Torres. "If they move out of state or pursue a different kind of service locally, they can take their session notes to their next provider. This process gives the new provider a comprehensive history and helps them make more informed treatment decisions."

Torres also points out that session notes can help you catch data collection and documentation discrepancies. "For example, let's say that the data on a particular day deviates from the norm. In that case, you can look to the session notes to see what happened that day. In many cases, you'll find that the data doesn't match up with the session notes summary—indicating an error in data collection. Without access to these notes, it becomes challenging to cross-check such discrepancies, potentially leading to clinical consequences."
Substantiate billing
"If a session isn't therapeutic or medically necessary, the insurance payor won't pay for it," explains Torres. "Your session notes are where you show why the session was medically relevant and necessary."

ABA Session Notes Insurance Requirements

Most insurance payors don’t require session notes to make a claim. When payors audit claims, they require session notes to prove that the provider performed a service. Session note requirements vary, but most payors require details about the patient, provider, and specific interventions.

Payors request session notes whenever they decide to audit a claim. The session notes should support that the clinician performed the services on the claim and that the treatment was medically relevant. Although you don’t need session notes to submit a claim, they’re incredibly important to pass these inevitable audits. Insurance payors have similar session note requirements, although sometimes minor differences exist.

Ahmed Khan, Assistant General Manager at Calpion, Inc.

“When you submit an insurance claim, you use a diagnosis code to tell the payor what services you performed or need to perform,” explains Ahmed Khan, Assistant General Manager at Calpion, Inc. Khan has a wealth of experience spanning over 15 years in the healthcare industry, specifically in ABA revenue cycle management, business intelligence, transition services, quality assurance, and accounts receivable.

"This code, along with other information, is enough for the insurance payor to process your initial claim, which may go through cleanly with no issue," Khan says. "But payors often run claim audits to make sure that the provider is performing the services they are requesting payment for. At this point, session notes become incredibly important."

Specifically, session notes come into play whenever a payor wants to conduct a pre-payment review (PPR) audit on your claim. During a PPR, payors are looking for clear documentation that lines up with the information on the initial claim. “

Khan says it’s not “if” you’ll get a PPR audit but “when.”

“You won’t be able to pass an audit if you don’t have complete documentation that proves that you provided the services you are claiming, and that these services were necessary for the patient. If you’re not in the habit of keeping high-quality session notes, a payor will probably find something in your notes that doesn’t meet their documentation requirement, and they’ll deny your claim, which amounts to money lost.”

Khan emphasizes that you won’t know which dates of services a payor will select to audit. “The best way to approach these audits is to set up a solid documentation system that meets payor requirements,” he says. “Then, you know that if you receive an audit, you’ll have high-quality session notes to back up your claims.”

Khan underscores that different payors have different requirements, and it’s important to make sure you review these requirements with your major payors. He adds that all insurance providers want to see certain fields, so having them will help you pass any PPR audit. Khan says the key is to make it easy for the payor to see that you rendered the services you list on your claim. To do so, you must go beyond just summarizing your services in a few sentences.

“BCBAs and RBTs are busy. Most of them document every session, but everyone does it a little differently. Some do it immediately; others wait. Some focus on certain aspects of care, and others find something else, like data, more important. This variability means that, in the eyes of payors, most session notes aren’t very well-organized or easy to understand. In this case, even if you’re rendering the service correctly and faithfully, the payor might not see that reality reflected in your note.”

Khan continues: “To avoid this situation, it’s important to have templates with pre-defined fields for every piece of information that a payor requires. For example, the templates have a drop-down menu listing all the interventions that the provider can select from. There’s a space for the provider’s name, the client’s name, and more. Of course, the templates contain a blank field for a session summary. Using these templates simplifies the process for both insurance companies and healthcare providers: It’s easier for the payors to read quickly, and it’s much faster for the provider to write. Plus, they give the provider the assurance they need. If an audit does happen, they have nothing to worry about because they know that their session notes are comprehensive by default.”

Our free ABA session note template below includes all the categories that Khan and other experts say must be in every session note.

Expert Tips for Writing Effective ABA Session Notes

To write ABA session notes like an expert, follow some key tips: If possible, take notes immediately after the session. Use a template with pre-determined categories to fulfill all insurance requirements. Also, experts recommend writing notes on a computer with practice management software.

Here are more tips from clinical and insurance experts on writing ABA session notes that meet clinical and insurance needs.

Write professionally
Write in a professional tone and avoid casual language and abbreviations.
Collect notes as soon as possible
"The sooner you take the notes, the better," says Torres, BCBA. "If possible, clinic owners should allocate 15 minutes for RBTs to write their session notes at the end of the session. It's also important for clinicians to be able to edit their notes later, ideally via a practice management software."

Torres says having a notebook, tablet, or computer can help BCBAs and RBTs jot down quick notes during the session to flesh out afterward.
Have a system in place to cross out errors
If you're handwriting your notes, cross out any errors in pen, and then write your initials next to the error.
Use legible handwriting
If you're writing your session notes in shorthand, be sure to write legibly. Otherwise, the insurance payor may not be able to understand the entire note and might reject it without trying to clarify.
Ensure that longer sessions have more robust notes
"The length and level of detail in your session note should match the length of the session and the complexity of the interventions," explains Khan. "If an insurance provider sees that the session lasted two hours, but the notes are very thin, the discrepancy might raise a red flag."
Make sure your notes align with the provider's degree level
Khan also says BCBA session notes should differ from RBT session notes. "If the service involves a higher level of intervention and the involvement of both RBTs and BCBAs, insurance payors require notes from both professionals," he says. "The expectation is that BCBA session notes will be more complex and thorough than RBT session notes."
Use an ABA session note template
“It's easy for a clinician to forget to include basic information like their credentials, the date, or other non-clinical information,” Kahn says. “Session notes templates include segregated categories for every specific piece of information that a payor requires. If the template is part of an ABA practice management software, the software will alert you if a category is missing.”

Khan points out that templates won't just speed up your writing but will result in more focused, effective notes. “Templates give you the confidence that every session note you write will back up the claim you submit. They’re also a far more structured way to communicate what happened in the session to other important providers involved in the child's care, like doctors and other behavioral analysts."
Use electronic recording
Taking notes on a computer has become a standard practice, offering a more efficient, accurate, and organized way to handle documentation. Electronic notes are free from handwriting issues, and with the added benefit of spelling and grammar checks, they ensure typo-free, clear, and professional records. Use an ABA practice management software to fully leverage the advantages of electronic documentation. This software simplifies the notetaking process and synchronizes session notes within a single patient dashboard. Here, therapists can access an organized, comprehensive record of each patient, complete with ABA data collection, graphing, and more.

Common Mistakes to Avoid in ABA Session Notes

All clinicians occasionally make mistakes in their session notes due to human error. One common mistake is using subjective language. Another is forgetting to list all the interventions they used.

Here's a list of the most common mistakes in ABA session notes:

Including subjective language
"Save subjective observation for SOAP notes,” says Torres. “Session notes must be totally objective. It can be easy to miss moments when you're being opinionated. For example, don't write 'He had a good day' because that's a subjective assumption. Instead, just write down the specific client observations. For example, 'He laughed and smiled throughout the session.'"
Failing to include interventions
"Some clinicians do a great job of explaining the child's behavior, but fail to list all their interventions in a clear way," says Torres. "The intervention is the heart of ABA, so you want to include everything you did in detail."

Torres says that one way to make sure session notes provide enough detail is to have a system where another BCBA checks the session notes.

"In our clinic, a BCBA must sign off on every session note before we submit it to a payor. This process gets a second pair of trained eyes on everyone's notes and helps us catch errors before we submit them to an insurance company."
Not including the supervisor summary for complex interventions
“If the service involves a higher level of intervention and the involvement of both RBTs and BCBAs, insurance payors require notes from both professionals,” says Khan.
Forgetting basic details, like the provider's signature
Every detail in a session note must be complete, even if it seems obvious or redundant. A common mistake is to forget to sign the note with your credentials. Using an electronic system will likely alert you to any of these basic omissions and require you to fill them in before submitting the note.

ABA Session Notes Templates

Explore our ABA templates to help you write effective notes that meet all clinical and insurance needs. Each template includes all essential components and a filled-out example for reference.

Download our free ABA session notes templates

The templates include RBT session note examples and instructions on how to fill out each field. These templates include all the major categories most insurance payors require.

Using Technology to Assist with ABA Session Notes

Using tech in ABA therapy makes it easier for therapists to write and keep track of their notes. They can use digital tools to write notes quickly, add information immediately, make changes, and keep notes safe and secure. This software ensures that session notes are organized, accurate, and easily accessible.

“Taking session notes with an ABA Practice management software saves you so much time, helps you take more compliant notes, and takes away the stress of storing the notes somewhere safe,” Torres says. "This specialized ABA software has really helped BCBAs and RBTs shift their focus to what truly matters: meaningful client interaction, rather than getting bogged down in note management and paperwork.”

Here's a list of why ABA practice management software tech helps improve ABA session notes:

Automated templates
Automated templates in ABA software streamline notetaking by providing pre-designed formats specifically for ABA therapy clinical and insurance needs. This feature ensures that every session note captures all the information an insurance company could request.

“These templates are a guiding hand for therapists, helping them capture every important aspect of the session,” Khan explains. “The templates help therapists take quick and ¬¬focused notes, and equip them to withstand rigorous PPR audits. The templates also help therapists jot down every bit of information another professional might want to see later. They help leave no stone unturned.”
Accessibility
Cloud-based storage means therapists and their supervisors can access session notes from anywhere at any time. This flexibility is especially important for therapists working in multiple locations or needing to review notes outside the office.

"The ability to review patient information and session data from anywhere, be it at home or on the move, through my phone or laptop, has been incredibly beneficial,” says Torres.
Enhanced collaboration & customizability
ABA software allows multiple therapists and team members to access and contribute to the same session notes. This feature promotes a more cohesive treatment approach, as all team members can stay updated on client progress. It also helps the clinic ensure that multiple people review the session notes before submitting them to the payor. This practice helps ensure high-quality notes.

Torres says the option to revisit and refine session notes is invaluable. “The customizability feature allows us to elaborate on our notes, perhaps when we have more time later that day. This flexibility not only saves time but significantly elevates the quality of our documentation."
Integrated analysis and data collection
The best ABA practice management software is end-to-end, providing a holistic, comprehensive solution for all things ABA. It includes software solutions for everything, from billing to data collection to session notes. This software allows therapists to take notes, collect data, and analyze graphs on the same platform. The integrated approach saves time and provides a comprehensive overview of each client's progress, helping BCBAs and other ABA professionals develop tailored therapy plans.

Using ABA Practice Management Software for Session Notes

ABA practice management software includes session note templates that help clinicians take comprehensive notes. Artemis’ end-to-end software offers a holistic ABA solution with session notes, data collection, billing and more.

Artemis ABA stands as the industry leader in ABA practice management software. It employs advanced technologies like AI and machine learning algorithms to help ABA clinics optimize their practices and deliver superior care.

Artemis integrates session notes as a critical part of its comprehensive ABA practice management solution. It offers tailored templates for RBTs and BCBAs, ensuring compliance with PPR audits and enabling clinics to maintain thorough, comprehensive records that fulfill clinical and insurance needs. These templates are user-friendly, detailed, and accessible from anywhere. Plus, clinicians can easily switch between multiple active sessions to take notes on many patients at once.

Along with session notes, Artemis' end-to-end software integrates data collection, reporting, scheduling, billing, and more within its single, unified platform. You can efficiently switch between multiple active sessions for notetaking. Each patient's profile includes a dashboard with tools for data collection, scheduling, and behavior intervention plans. Additionally, advanced reporting and analytical tools enable you to understand whether your plan is working and develop personalized, data-driven approaches for each patient.

Artemis ABA is the unparalleled choice for clinics seeking to fully digitalize their ABA practice and enhance patient care.

ABA Session Notes: Components, Examples, Templates and Expert Tips

Inside this article:

What are ABA Session Notes?

Key Takeaways:

ABA Session Notes Vs. ABA SOAP Notes

Main Components of ABA Session Notes

Example of ABA Session Notes

Client Information

Appointment Details

Provider Information

Treatment and Session Details

Why ABA Session Notes Are Important

Here’s a summary of the main reasons why ABA session notes are important:

ABA Session Notes Insurance Requirements

Expert Tips for Writing Effective ABA Session Notes

Here are more tips from clinical and insurance experts on writing ABA session notes that meet clinical and insurance needs.

Common Mistakes to Avoid in ABA Session Notes

Here's a list of the most common mistakes in ABA session notes:

ABA Session Notes Templates

Using Technology to Assist with ABA Session Notes

Here's a list of why ABA practice management software tech helps improve ABA session notes:

Using ABA Practice Management Software for Session Notes

Keep Up to Date on ABA Practice Management Best Practices

Thomas John, CEO of Artemis ABA

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