5 Rules For Language To Use in an ABA Session Note

It's the end of the day. You've just had 8 back-to-back hours of chaotic sessions and significant behaviors.

You want to go home, microwave some chili, and watch TV.

But… you get a text: "Don't forget to finish your session notes"

From BTs to BCABAs to BCBAs to the admins who support clinical operations, session notes is the bane of every ABA professional's existence.

Whether you're a seasoned BCBA or an RBT writing session notes for the first time, following these five rules will help ensure your documentation meets the highest standards.

Why Do Session Notes Matter?

We know that session notes are critical to get paid and avoid audits from insurance. After all, a signed session note confirms that a scheduled session actually happened. Only with a signed session note (often referred to a "converted session note") should an ABA clinic send a claim to insurance.

Why? Insurance companies conduct audits to ensure compliance with billing regulations, detect fraud, and verify that services billed were medically necessary and appropriately documented. For example, private insurers may audit claims that show unusual billing patterns, such as excessive units of a specific service or frequent high-cost procedures. Government payers, like Medicaid and Medicare, routinely perform audits to prevent improper payments, often triggered by high utilization rates or discrepancies in provider documentation. Some government payers, such as TRICARE, require annual audits to assess program integrity and ensure that providers adhere to their policies.

If claims are sent without signed session notes, your clinic will fail an audit and the insurance will clawback previous payouts.

There's nothing better than getting paid. But, there's nothing worse than getting un-paid.

But, session notes are not just about getting paid. Accurate documentation enables continuity of care and leaves a clear record of clinical practice. In a field where BT and BCBA turnover can be so high, session notes can help new clinicians get up to speed on a case.

1. Be Objective and Data-Driven

Session notes should focus on observable and measurable behavior rather than subjective interpretations. Avoid using opinions, assumptions, or emotionally charged language. Instead, describe exactly what occurred using quantifiable data or observable behaviors.

As practitioners of Applied Behavior Analysis, it's important that we focus on behaviors and not emotions. ABA is rooted in the science of observable and measurable behavior, meaning that session notes should describe what the client did rather than why we think they did it. This principle helps maintain objectivity and ensures that interventions are based on data rather than assumptions about a client's emotions, thoughts, or intentions.

Using mentalistic language—which attributes behavior to internal states like “angry,” “frustrated,” or “stubborn”—can lead to subjective and unverifiable documentation. Instead, ABA practitioners should describe behaviors in observable terms, noting the frequency, duration, and intensity of the actions.

Instead of writing, "she was happy", describe why you thought she was happy.

✅ GOOD Examples:
✔️ "The client engaged in hand-flapping for 3 minutes when presented with a non-preferred task."
✔️ "The client followed a one-step direction on 4 out of 5 trials with verbal prompting."
✔️ "The client engaged in screaming (volume above conversational level) and hitting the table five times following task presentation."

❌ AVOID:
🚫 "The client seemed frustrated and didn’t want to do the task."
🚫 "The client had a meltdown and was difficult to manage today."
🚫 "The client refused to cooperate."

Why it matters: Objectivity ensures accuracy and prevents misinterpretation, which is essential for insurance reimbursement and treatment planning.

2. Use Professional and Concise Language

Avoid slang, jargon, or overly complex wording. Keep your notes clear, professional, and to the point while maintaining necessary detail.

ABA is a medically necessary therapy, yet many insurance providers mistakenly equate it with daycare or non-medical services. This misunderstanding can impact reimbursement rates, treatment authorization, and the overall perception of ABA as a legitimate, evidence-based medical practice.

Because of this, it is critical that all session notes maintain a professional tone that aligns with other healthcare disciplines. Professional, well-documented notes not only help secure insurance approvals but also reinforce the legitimacy of ABA as a science-backed intervention for individuals with autism and other developmental disabilities.

✅ GOOD Examples:
✔️ "The client completed 8 out of 10 trials of the receptive labeling task independently."
✔️ "A visual schedule was introduced, and the client followed it 75% of the time with gestural prompts."
✔️ "The client remained seated for 15 minutes during structured activities with one reminder."

❌ AVOID:
🚫 "The client totally nailed the labeling task today!"
🚫 "He was kind of all over the place during the session."
🚫 "Client had a great session!"

Why it matters: Clear and professional language ensures that anyone reading the note—whether another clinician, an insurance reviewer, or a caregiver—can easily understand the session’s events.

3. Describe Interventions and Responses Clearly With ABA-Specific Language

Always document the specific interventions used and the client’s response. This helps demonstrate the effectiveness of the treatment plan and ensures continuity across providers. However, not every single program and data point needs to be included in the session note, as these details are often pulled from data collection systems. Instead, focus on noteworthy interventions, significant progress, or major challenges that occurred during the session.

ABA is a science-based discipline with its own terminology, and using correct ABA terminology reinforces the professionalism and credibility of session notes. Avoid vague descriptions and instead document the intervention using precise ABA terms.

✅ GOOD Examples:
✔️ "A token reinforcement system was used, and the client earned 5 tokens before exchanging them for a preferred item."
✔️ "When presented with a first/then visual, the client complied with the demand in 3 out of 5 trials."
✔️ "A differential reinforcement strategy was implemented to reduce vocal scripting, resulting in a 50% decrease over the session."

❌ AVOID:
🚫 "The client did well with reinforcement today."
🚫 "We tried some visuals, and they worked okay."
🚫 "The client was cooperative and listened well."

What to Include in Session Notes?

🔹 Significant Progress:
✅ "The client independently labeled 5 new items without prompting, indicating skill acquisition."

🔹 Challenges & Barriers:
✅ "The client engaged in aggression (hitting therapist) when transitioning from a preferred to a non-preferred activity. Redirection and reinforcement were used, and the client transitioned successfully after 3 minutes."

🔹 Adjustments to the Treatment Plan:
✅ "Prompting was faded from full physical to partial physical in the hand-washing routine, and the client completed 4 out of 5 steps independently."

Why ABA language matters: Proper terminology ensures clarity, consistency, and compliance with insurance documentation standards.

4. Use Neutral and Nonjudgmental Language

Avoid words that imply judgment about the client’s behavior. Instead, describe actions factually without assuming intent or emotion.

✅ GOOD Examples:
✔️ "The client engaged in screaming and hitting the table five times when denied access to a preferred item."
✔️ "The client left their seat and ran to the door on three occasions when given a non-preferred task."
✔️ "The client demonstrated noncompliance by pushing materials away and turning away from the therapist for 5 minutes."

❌ AVOID:
🚫 "The client threw a tantrum because they were angry."
🚫 "The client acted out when they didn’t get what they wanted."
🚫 "The client was being stubborn today."

How to Ensure Neutrality in Session Notes

• Stick to observable behaviors – What did the client do? How many times? How long did it last?

• Avoid interpreting emotions – We don’t know what the client is feeling unless they verbally express it.

• Use clear descriptions – Instead of saying "The client was mad", describe the behaviors observed (e.g., "The client clenched their fists and stomped their feet for 10 seconds after being denied access to a preferred item.").

• Be consistent – Use standardized, clinical language in every session note to maintain professionalism and accuracy.

Why it matters: Neutral language ensures that the session note remains professional, reducing bias and maintaining the clinical integrity of the document.

5. Avoid Clinic-Specific Terms

Many insurance companies and regulatory bodies do not recognize clinic-specific names, abbreviations, or branding. Instead, use general terminology to ensure clarity and prevent claim denials.

✅ GOOD Examples:
✔️ "The client participated in group instruction."
✔️ "The session took place in a treatment center."
✔️ "The client attended a clinic-based session."

❌ AVOID:
🚫 "Early Learning Academy (ELA)"
🚫 "Huge Play Room (HPR)"
🚫 "Discovery Room"

Why it matters: General terms ensure that the session note is universally understood and avoids insurance claim denials due to unfamiliar terminology.

Final Thoughts

Writing effective ABA session notes requires clarity, professionalism, and objectivity. By following these five rules, practitioners can ensure their notes support client progress, comply with insurance requirements, and reinforce ABA’s status as a clinical field.

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