What are Objective Session Notes?
Session Notes become part of the client's medical record. They must be Objective and Measurable.
Objective = Facts (What you saw/heard).
Subjective = Opinions (How you felt/interpretation).
Objective vs. Subjective Examples
| Subjective (BAD) | Objective (GOOD) |
|---|---|
| "He was angry." | "He screamed and hit the table." |
| "He was happy." | "He smiled and laughed." |
| "He was lazy." | "He put his head down and did not respond." |
RBT Practice Exam Scenario
Question: "Which of the following is an objective session note?"
Answer: "Client engaged in 3 instances of hitting." (Not "Client felt aggressive").
Frequently Asked Questions About Notes
When should I write notes?
Ideally, during the last 10 minutes of the session or immediately after. Do not wait until the next day (memory fades).
What goes in a note?
1. Target behaviors (data).
2. Interventions used.
3. Client response.
4. Any setting events/variables.