ABA Session Notes Examples (With PDF Download)

Many types of notes are used in mental health, including ABA session notes, BIRP, DAP, group, and progress notes. Choosing the right one for your practice can be challenging.

As an experienced therapist, you may already have an idea. However, let’s take a closer look at one of the most common types: ABA session notes.

We’ll explore what they are, how they’re used, and provide real-life examples. Let’s dive in!

What is an ABA Session Note?

An Applied Behavioral Analysis (ABA) note is a type of SOAP note typically used by an ABA service provider or Registered Behavior Technician (RBT), to track and address communication issues, motor skill deficits, and other behavioral disorders. Though an ABA session note is technically a form of SOAP note, the two are inherently different in a few subtle ways. SOAP, which stands for Subjective, Objective, Assessment, & Plan, is a more general form of session note used for documenting patient progress, as well as their interactions during your therapy session. An ABA session note, on the other hand, often includes more data than a regular SOAP note would, like daily treatment plan data, preference assessment data, specific behaviors observed during the session, or even the materials used or required for the session(s). What about RBT session notes, though? Glad you asked!

RBT v.s. ABA

RBT session notes are crucial for tracking progress, challenges, and successes in each therapy session. They help monitor client growth. They ensure the Behavior Analyst Certification Board (BACB), family, and caregivers stay aligned.

RBT and ABA session notes serve distinct purposes, though they are similar. RBT notes focus on applying techniques and collecting data. ABA session notes take a broader approach, emphasizing analysis and treatment planning.

SOAP Notes: The Basics

Before we start writing an ABA session note, it’s important we touch on what a SOAP note actually is. Here's the rundown:

S(ubjective): The Subjective aspect of your SOAP note is meant to document information relevant to the patient’s current condition. This information must come directly from the patient or a guardian of the patient. The data tracked in your Subjective section should not be measurable and should instead be a direct description of their status. Be sure to avoid using opinionated language or documenting irrelevant information. This section often only needs to be three to four sentences long.

O(bjective): The Objective section of your SOAP note is meant to capture things that are absolutely factual about the patient. Things like physical appearance, attitudes, and mannerisms should all be noted in this section. Anything that occurs during the session between the client and the therapist must be written here as well.

A(ssessment): The Assessment portion of your SOAP note is meant to bridge the gap between your Subjective and Objective sections and document the actual progress of the client. How has the current treatment been working? What kind of side effects do you notice it has had on the client? The Assessment section should also track any new or different diagnoses in comparison to other sessions. This section should highlight any positive change observed in the client's therapy progress.

P(lan): The final section of your SOAP note, the Plan section, is exactly what you would expect it to mean. This portion of your note includes what kind of practices, mechanisms, or interventions you’re going to attempt in subsequent sessions with the client. You can include any progression or regression that the client has made from previous sessions. However, the future should be the primary focus of this section.

Why We Use ABA Session Notes: The Practical Application

In today’s practices, ABA notes are often used when working with children with autism spectrum disorder (ASD), but can be used for a pretty wide range of clients. Of course, the end goal of ABA therapy is to help said clients further hone traits or skills that'll promote not only their independence, but their personal success as well. So, to determine the effectiveness of ABA therapy, it's crucial we use ABA notes to evaluate things like the client's user interactions, individual nuanced characteristics, or potential changes in behavior.

Your clients or their families might already practice ABA therapy principles in their day-to-day life without even realizing it, too, but most are intentional about it. Some examples might include awarding a child dessert after they finish their dinner, breaking seemingly larger tasks into steps, or telling someone they did a Good Job after they finish up their chores for the day. These are all cases where ABA is practiced!

Okay, now that we have an understanding of what a general SOAP note is, let’s take a look at an actual ABA SOAP note template created in Vagaro!

ABA Notes: Session Checklist

Here are a few things to remember before you get started with creating your first ABA session note. Take a look at the checklist below to ensure that you’re effectively writing your notes and including all the information necessary for you & your clients’ success.

• Patient’s full name

• Patient’s DOB

• Session date & time

• Location (Virtual/telehealth or in-person at practice)

• A clear narrative documenting the therapy or interventions used, as well as any responses to such mechanisms

• Network management trends and online interactions relevant to the session

ABA Notes: What to Avoid

• Extravagant vocabulary that might distract from the core message

• Opinion-based entries; only document absolute fact

• Writing notes too far after the session has concluded. Instead, write notes 24–48 hours following a session for validity.

If you want to take your session documentation a step further, check out how using Vagaro’s HIPAA-compliant form builder to create and document your own session notes for your practice. You can eliminate the hassle of managing session notes with pen & paper, thus streamlining your practice’s business flow.

Vagaro can do so much more than just help you document your sessions, though. Vagaro is an all-encompassing business management tool, meant to help with anything your practice might need. Get started with 30-days entirely free. To see a specific list of all the Vagaro features that would be especially beneficial to you as a mental health practitioner, take a look at our Software for Practice Management article!

Sources:

1. https://www.mentalyc.com/blog/aba-notes