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Report Verified Requirements
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Service Delivery 
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Report Verified RequirementsPages Viewed: 100%

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Service Delivery

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IMPORTANT: Note from the training team

  • Throughout each section, there will be 3 codewords!
  • These codewords will be entered as an exit ticket and checked by the team
  • We recommend jotting down the code words throughout so you don't forget them!
  • Once you've finished the lesson, you'll enter it in the Code Word Submission section of that lesson! You will not be able to see other people's responses until you have posted your own! You will not be considered complete until this posting has been verified.

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IMPORTANT: Note from the training team

  • There will be TWO Code Words in the Role of the RBT lesson, and ONE in the Service Delivery lesson!
  • All three will be entered together as the code words for this section!

Index

Text + Image
Highlighted Phrase
Section
Relevant Data
Timeline
Chart + Text
Table + Text

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List / Processes
Video

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Text + Icons

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Audio
Embedded Content
Interactive Question
Conclusions
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4. Communicating with clinical teams on concerns or suggestions

2. When and how to document service delivery

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3. Documenting and reporting in a timely manner

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1. Importance of maintaining confidentiality and documentation

Index

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Importance of Maintaining Confidentiality and Documentation

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Confidential Information

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Behavior analysts take appropriate steps to protect the confidentiality of clients, stakeholders, supervisees, trainees, and research participants. They prevent the accidental or inadvertant sharing of confidential information and comply with applicable confidentiality requirements (e.g., laws, regulations, organization policies). The scope of confidentiality includes service delivery (e.e., live, teleservices, recorded sessions); documentation and data; and verbal, written, or electronic communication.

Confidentiality means respecting someone's privacy, and abstaining from sharing personal or potentially sensitive information about an individual, especially if that information has been shared in confidence. This also includes confidential documents you may have in the work place that contain case sensitive information.

What is Confidentiality and Documentation?

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HIPAA

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This refers to someone directly involved in the clients treatment or care. This could include:

  • Clinical Leader
  • Clinical Director
  • CBT/RBT assigned to the case
  • Clients primary healthcare provider
  • Legal Representatives
  • Any individual designated byt their legal guardian to receive information about their healthcare.

Who is an authorized individual?

How do I Maintain Client Confidentiality?

To maintain client confidentiality, we must ensure we are following HIPAA Guidelines.HIPAA, the Health Insurance Portability and Accountability Act, impacts Behavior Techicians by requiring them to maintain strict confidentiality regarding clients' health information. RBT's must ensure that all client information is securely stored and only shared with authorized individuals, adhering to HIPAA guidelines to protect clients' privacy and confidentiality

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hover over each picture to reveal what HIPAA is!!

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What is HIPAA?

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Add follow up question

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Intro to PHI

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  • PHI (protected health information) all individually identifiable health information and other information on treatment and care that is transmitted or maintained in any form or medium.
  • Non-PHI Information that DOES NOT include personal identifiers like names, addresses, or Social Security numbers

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Before we discuss what is protected through HIPAA, we must understand the difference between PHI and non-PHI.

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What is Protected Through HIPAA?

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PHI Includes:
  • Client Names
  • Addresses
  • Phone Numbers
  • Social Security Numbers
  • Client School Names
  • Medical Record Numbers
  • Full Face Images
  • Mental Health Evaluations
  • Planned Medical Situations

HIPAA Protected PHI

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add in PHI vs non PHI quiz

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add in PHI vs non PHI quiz

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add in PHI vs non PHI quiz

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Where can I find the BACB's specific confidentiality requirements for BTs/RBTs?

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In Section 2.03 of the RBT Handbook!

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2.03 Protecting Confidential InformationBehavior analysts take appropriate steps to protect the confidentiality of clients, stakeholders, supervisees, trainees, and research participants; prevent the accidental or inadvertent sharing of confidential information; and comply with applicable confidentiality requirements (e.g., laws, regulations, organization policies). The scope of confidentiality includes service delivery (e.g., live, teleservices, recorded sessions); documentation and data; and verbal, written, or electronic communication. Updated 01/2023, Copyright © 2020, BACB® | All rights reserved. Behavior Analyst Certification Board | Ethics Code for Behavior Analysts |

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In Section 112.04 of the RBT Handbook!

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112.04 Disclosing Confidential InformationBehavior analysts only share confidential information about clients, stakeholders, supervisees, trainees, or research participants: (1) when informed consent is obtained; (2) when attempting to protect the client or others from harm; (3) when attempting to resolve contractual issues; (4) when attempting to prevent a crime that is reasonably likely to cause physical, mental, or financial harm to another; or (5) when compelled to do so by law or court order. When behavior analysts are authorized to discuss confidential information with a third party, they only share information critical to the purpose of the communication.

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Summarizing Maintaining Confidentiality and Documentation

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Summarizing Maintaining Confidentiality and Documentation

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Summarizing Maintaining Confidentiality and Documentation

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Summarizing Maintaining Confidentiality and Documentation

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Summarizing Maintaining Confidentiality and Documentation

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When and How to Document Service Delivery

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What is Service Delivery Documentation?

As clinicians it is our responsibility to report out on services that were provided. Quality, objective documentation and reporting is an essential component to ensuring that services are documented appropriately, financial reimbursement can be obtained for services provided, and that others are able to review and assess services and progress.

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Documentation of sessions will be placed in the clients personal records, and will be reviewed by clinical teams, insurance providers, client families and more.

Documenting service delivery is not only a part of our responsibility as RBTs, but it allows our clinical teams to view and observe client progress and make any changes as needed.

Why is Documenting Service Delivery Important?

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While the specifics of what should be included in RBT and ABA notes may vary by company, here at CSD we request:

  • The therapists' names
  • Session date and time
  • Teaching techniques utilized
  • Client's reaction to therapy
  • Progress made on skills/targets
  • Coordination of care (communication between stakeholders)
  • The therapist's signature

What Should be Included in a Service Document (i.e., a session note)?

Session notes or any form of document that is about the session that occured or relevant to client updates MUST be done immediatley after session or contact.

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After session is completed you must write a report on the session that occured. Behaviors that occured. and what information that might be relevant to clincial teams.

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When Do We Write Our Reports on Sessions that Ocurred?

Click each icon above to learn more!!

There are many factors that an RBT should consider regarding a client’s progress. ​​Some examples of these events include: ​Illness, ​Lack of sleep​, Biological needs (like hunger) ​Changes in the client’s home environment/medication/schedule changes

HIPAA Compliant

Observable

Objective

Measureable

What Do We Include in Session Notes/Documents

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What does it mean?

Measurable

DATA COLLECTED DURING SESSION

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CLIENT PROGRESS

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INFORMATION MUST BE ACCURATTE

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What does that mean?

HOW LONG WAS SESSION, WHERE WAS SESSION HELD, GOALS AND PEOPLE INVOLVED

Objective

INFORMATION MUST BE ACCURATTE

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KEY ASPECTS THAT HAPPEN DURING SESSION

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add in questions for objective

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What does that mean?

Client Behaviors

Observable

ANY POSSIBLE BARRIERS THAT COULD HAVE OCCURED DURING SESSION

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KEY ASPECTS THAT HAPPEN DURING SESSION

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CANNOT INCLUDE identifiable health information

HIPAA Compliant

CANNOT INCLUDE CLIENT NAME

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CANNOT INCLUDE IDENTIFYING INFORMATION

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add in question on HIPAA

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Not only do RBT notes help organize clients’ sessions, but they are also crucial when creating actionable treatment plans, tracking clients’ progress, identifying trends, patterns in behavior, and making informed decisions that can be shared with interdisciplinary team members.

Why Do Session Notes Need to be Accurate

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Ask yourself…​​Did I use Measurable terms? (Percentage/Rate/# of trials)​​Did I use Objective language? (Facts/Information)​​Is my language Observable?​​If someone were to read my notes, could they visualize what happened?

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Document and Reporting in a Timely Manner

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Generally speaking, clinical observations and/or data and records of a treatment should be recorded concurrently with or as soon after the assessment/treatment as possible. As a matter of common sense, the longer the delay in making such records, the less reliable they will be

Documenting and Reporting in a Timely Manner

Reportable Events

Enviornment/Medication/Schedule Changes

Changes in the Home

Illness

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Changes in Behavior

What Should be Documented?

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If you are unsure of protocol or steps you should be taking in a wide range of scenarios regarding your clients, you must contact a supervisor in a timely manner in order to achieve clear guidance before your next session

What do I do?

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Why Do We Document?

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  • Documentation and reporting is one of the essential job responsibilities of an RBT. Just like in other human services fields and in the medical field, quality and objective documentation and reporting is an essential component to ensuring that services are documented appropriately, financial reimbursement can be obtained for services provided, and that others are able to review and assess services and progress.

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04

Communicating with clinical teams on concerns or suggestions

Electronically

Face to Face

What are different Modalities to communication?

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  • New client Behaviors
  • treatment plan seems to not be affective
  • questions about inplementation
  • guidance on what to do during session
  • concerns in the client space/home
  • Additional training​
  • Clinical guidance​
  • Reporting an uncomfortable situation​
  • Working with client families

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What concerns might I have?

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You can set up 1:1 meetings when you need extra support, or guidance, or if you have any information that may be of concern. ​

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Concerns to communicate can also be Unsafe or Unlawful situations.

Unlawful situations are relatively easy to identify but not necessarily easy to resolve.

Unsafe situations are categorized as environments or instances where the safety, health, and/or well-being of a person is jeopardized.

UNLAWFUL

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UNSAFE

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Remember as RBTS suggestions are welcomed. But ALL suggestions must go through the clinical teams and receive approval before being implemented during session. Clinical teams will then add the suggestions/changes to client treatment plans/targets.These suggestions also CANNOT be discussed with families before proper channels and approvals are given. Clinicals teams/supervisors will discuss the changes with families.

  • Changes to treatment planning
  • adding new goals
  • trying something new during session
  • wanting to run more goals
  • change pace during session

What suggestions might I have?

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if you are unsure of protocol or steps you should be taking in a wide range of scenarios regarding your clients, you must contact a supervisor in a timely manner in order to achieve clear guidance before your next session (in most cases).

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What if I dont know what to do?

What are some requirements with the BACB?

Effectively communicate with a supervisor in an ongoing manner.

E-1

Actively seek clinical direction from supervisor in a timely manner.

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Communicating with teams on concerns and suggestions wrapped up

You should always communcate with clinical teams on concerns and suggestions. Sometimes these concerns and suggestion could be in regards to client safety, client programming or unsafe and unlawful situations. As RBTs it is always a priority to ensure our clients safety and that they are receiving ethical treatment during session.

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CSD Specific Session Notes

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Objectives of a session notes

Report out on what happened in session.​ Provide documentation to insurance.​ Explain any behavior of concern and how behavior plan was followed.

Session Note Requirements

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MOO

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O: Is my language Observable?

​ O: Did I use Objective language? (Facts/Information)

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M: Did I use Measurable terms? (Percentage/Rate/# of trials)

Remember MOO

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How to write a session note

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The Session Narrative is where you will write your Treatment Target summaries. Remember, you must write a narrative on 3-5 goals. The goals must be relevant to session, or be significant in a way. The Data will be pulled automatically when you choose the session data to generate. Be sure you ALWAYS complete this FIRST! It makes writing your session narratives easier when needing to review the data.

Session Narrative/Targets Implemented

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To view the data from your session you must click "select session summary".

Session Narrative/Targets Implemented

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After you click "select Session Summary" you will get a list of available data sheets to select. Select the corresponding data sheet to view the data.

Session Narrative/Targets Implemented

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This is what the data will look like when you pull it into your session note. Here you are able to view the goals you want to report out on the data.

Session Narrative/Targets Implemented

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When writing out activities they must be relevant to when that goal was ran. These can be full sentences, lists, or activities as long as whoever is reading can visual what was occuring.

Activity Section

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Your results section must include the target, the data and the activity. In this section you are summarizing what happened when these trials were ran. Remeber to use client codes and refrain from using subjective language.

Results Section

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This section should be 2-4 sentences long. Remember MOO, Measurable, Observable and Objective.

Results Section

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Make sure to write this down!

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Code Word 3:

OBJECTIVE

Once you've viewed both lessons, submitted the code words and completed the post-test, you'll be able to view the slides without the time requirements!

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As an RBT you should report concerns/suggestions to your supervisors in a timely manner. A good rule to have is within 24 hours. (hint: do not go a week running treatments that you are concerned about)

When registered with the BACB under an RBT credential, all specialists will receive the RBT handbook. Inside you will find BACB guidelines for RBT practice.

HIPAA is to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.

Objective means with a basis in observable facts rather than feelings or opinions.

As an RBT you should keep ongoing supervision/communcation with you supervisor. (hint: you should not only be talking to your supervisor once a month)

It is your responsibility as an RBT to seek out guidance and direction from your supervisor(s) when needed. ​​

Confidentiality

  • Confidentiality means respecting someone's privacy, and abstaining from sharing personal or potentially sensitive information about an individual

Measurable is the ability to be described in specific terms (percentage, duration, frequency) usually expressed as a quantity.

The sooner you seek guidance the better! Make sure you are communicating in a timely manner to ensure all goals and interventions are running according to programming.

Observable is the ability to be noticed or perceived; discernible.

See the results of the questions