Practice makes perfect, as they say. Here are some examples of RBT (registered behavior technician) session notes to help you understand how to document your observations and interventions during behavior therapy sessions.
Example 1
Subjective: The client reported feeling anxious about starting a new task.
Objective: The client demonstrated hesitant behavior when presented with a new task, including avoiding eye contact and fidgeting.
Assessment: The client may be experiencing anxiety related to task avoidance behavior. Behavioral intervention strategies may be implemented to increase the client's comfort and confidence in completing the task.
Plan: Implement a desensitization program to gradually increase the client's exposure to the new task and reinforce appropriate behavior.
Example 2
Subjective: The caretaker reported changes in the client's sleep pattern.
Objective: The client appeared fatigued during the session, demonstrated slower response time, and yawned frequently.
Assessment: The client's fatigue may be impacting his ability to engage in therapy. A medical evaluation may be necessary to rule out any underlying medical causes.
Plan: Consult with the client's physician and adjust therapy schedule as needed to accommodate for changes in the client's sleep patterns.
Understanding RBT Session Notes
叶根特（RBT）是行为疗法中的一项关键技术，并且具有高度的具体性和复杂性。RBT负责实施和监控基于奖励和消极后果的行为疗法技巧。在每个治疗会话中，RBT都会记录一系列关键数据：
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**主观描述：**RBT应记录客户的主观体验，如焦虑或疲劳水平的变化。
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**客观观察：**RBT应关注并详细记录客户端在会议期间的具体行为，例如避免特定任务、睡眠模式的改变等。
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**评估部分：**RBT将基于客户的主观观察和客观行为来分析其进步和可能存在的挑战。
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**计划方面：**RBT提出未来工作中必须采取的步骤，如调整治疗计划以适应客户变化的症状。
这些会话笔记对儿童行为疗法的持续监测至关重要。通过记录和分享信息，可以提供治疗有效性的有力证据，这对于获得保险报销也是必需的。此外，会话笔记有助于确保多个专业人员之间的沟通一致，并为临床干预提供详细的背景。