Documentation and Reporting
Documentation and reporting
Documentation creates a factual, contemporaneous record. Write objective descriptions of observable events: what happened, when, where, who was present, what was said or done, and the response. Avoid labels, opinions, and speculation (‘angry,’ ‘manipulative,’ ‘wanted attention’). Use quotes when exact wording matters. Session notes should link to goals, data, interventions, and response to intervention. Incident reports describe injuries, aggression, restraint, or unusual events without blame and are completed promptly per policy. Graphs and data sheets must be accurate, dated, and attributable; correct errors according to agency procedure rather than covering them up. Confidentiality is required: share only with authorized persons, secure records, and follow HIPAA/FERPA and organizational rules. Mandated reporting duties override confidentiality when abuse or neglect is suspected. Report to supervisors promptly and within required timelines. Traps: subjective language, missing times, late entries, altering another person’s record, discussing clients in public, and including unnecessary identifying details in emails. Also distinguish observation from interpretation. Worked example: Instead of ‘Client was defiant and lazy,’ write: ‘At 10:15 a.m. in the classroom, after being asked to start math, client said No twice, pushed the worksheet away, and put his head on the desk for 4 minutes.’ Rule of thumb: if you did not see or hear it, do not document it as fact.