RBT PROGRESS NOTE

Don’t do

1. No escriban la nota en términos mentalistas o usando lenguaje

subjetivo sin explicarlos de forma observable y medible. No usar los
términos como ansioso, frustrado, depresivo, preocupado, feliz,
angustiado, etc., sin explicarlos de forma observable.
2. No usen términos mentalistas o técnicas psicológicas cuando hacen
alusión a las intervenciones como: Relaxation techniques, breathing
exercises, self-control strategies, calming techniques, etc.
3. No hagan mención específica del progreso del cliente en términos
descritos a continuación, dado que esa no es una tarea de los RBT:
 Client’s progress is on STO 2 for eye-contact at this moment.
 Client mastered all his acquisition skills, so new skills must be added on the Behavioral
Treatment Plan.
 No new ABA therapy goals were added.
4. Debe existir relación o cierta concordancia entre la explicación
escrita vs data collected: maladaptive/replacement.
5. Las notas no pueden ser un copy & paste unas de otras
6. Tener cuidado al escribir la nota con los pronombres she, he, her,
him, I.
7. Cuidado al usar el traductor.

Do

1. Pueden empezar la nota con una oración general. Example: RBT met
with client (NAME) and client’s caregiver (NAME) at previously agreed
upon time in/on/at (PLACE OF SERVICE).
2. Escribir como estuvo, como fue la participación del cliente en general
en términos observables y medibles durante la sesión en particular.
3. Pueden describir que tipo de ayuda están usando en al menos dos o
más diferentes tipos de programas de reemplazo que hayan
implementado en la sesión.
4. Pueden cerrar la nota usando una oración general como, por ejemplo:
RBT collected client’s behavioral data along the session. No medical or
safety concerns arose during the session. During next session, RBT
will keep working on client’s BTP goals and objectives.
 5. Pueden describir con más precisión si hubo un factor ambiental que
influyo en la participación del cliente en esa sesión en particular.
6. Intenten hacer oraciones cortas y simples para evitar confusiones.
7. Pueden describir si trabajaron en algo relacionado con la
generalización o el mantenimiento de alguna conducta.
8. Pueden describir el antecedente de las conductas problemas (revisar
anexo donde tienen diferentes tipos de oraciones en dependencia de la
función de la conducta)

Anexo:

Ejemplo de nota:

During today's session, RBT met Client name and her/his caregiver at home at the
agreed time for therapy. RBT implemented reduction intervention procedures and
replacement programs. In this session, Client name displayed incidents of: “task
refusal”, “tantrums”, “stereotype behaviors” and “waiting difficulties”. Tantrums
occurred when an activity ended, and she/he was asked to comply with another
planned task or when she/he could not get the desired item. Task refusal occurred
when client was asked to perform a task or to participate in activities. Stereotypes
were observed while she/he was completing planned activities. RBT didn't observe
a clear prior event. Episodes of waiting difficulties occurred when she/he wanted a
preferred item or activity but she/he needed assistance to obtain it or when she
has to wait for an instruction. Overall, Client name had difficulties to engage in
requests to complete non-preferred activities as well as manage transitions from
non-preferred to preferred tasks. RBT worked with cards to provide opportunities
for developing observation, deduction problem solving and storytelling. I used a
handwriting workbook to implement replacement program: "Copy simple drawings".
She/He was observed having difficulties to find objects following two or more
steps. Client name needed gestural and verbal prompt to find the objects. Progress
has been noticed in program "Cause and effect" where client was able to provide a
correct statement of cause or and effect from multiple choice answers. Prompted
and unprompted responses were reinforced. Client name responded to praising,
prompting and edibles reinforces. I used Errorless learning and DTT to implement
replacement programs. Next session, RBT will continue working with Client name
according to the Behavior Plan.
Durante la sesión de hoy, RBT se reunió con el Cliente y su cuidador en el hogar a la hora acordada para
la terapia. RBT implementó procedimientos de intervención de reducción y programas de reemplazo.

Ejemplos de antecedentes en dependencia de la función de la

conducta:
Sensory observation of this behavior

Observación sensorial de este comportamiento.

The behavior occurs continuously when the client was left alone for long periods of
time.

El comportamiento se produce continuamente cuando el cliente se quedó solo durante

largos períodos de tiempo.

The behavior occurs repeatedly, in the same way, for long periods of time when the
client was alone.

El comportamiento ocurre repetidamente, de la misma manera, durante largos períodos

de tiempo cuando el cliente estaba solo.

It appears to me that the person enjoys doing the behavior.

[It feels to me, it tastes to me, it looks to me, it smells to me, it sounds
pleasing to me]. (please select one )

Me parece que la persona disfruta haciendo el comportamiento.

[me parece, me sabe, me parece, me huele, me parece agradable]. (Por favor,

seleccione uno )

When the behavior is occurring the client seems calm and unaware of anything else
going on around her/him.

Cuando se produce el comportamiento, el cliente se ve calmado y no se da

cuenta de nada más a su alrededor.

Escape observation of this behavior

Observación de escape de este comportamiento

The behavior occurs following a request to perform a difficult task.

El comportamiento se produce después de una solicitud para realizar una

tarea difícil.

The behavior occurs when any request is made at the client .

El comportamiento se produce cuando se realiza cualquier solicitud al cliente .

The client seemed to do the behavior to upset or annoy me when I am trying to get
him/her to do what I ask. [10]
 El cliente parecía hacer el comportamiento para molestarme o irritarme
cuando intento que haga lo que le pido .

The behavior stops occurring shortly after (one to five minutes) when I stop working
with or making demands of the client .

El comportamiento deja de ocurrir poco después (de uno a cinco minutos)

cuando dejo de trabajar con el cliente o dejo de hacerle demandas .

Attention observation of this behavior

Observación de la atención de este comportamiento

The client ’s behavior seems to occur in response to me talking to other persons in

the room/area.

El comportamiento del cliente parece ocurrir en respuesta a cuando yo estoy

hablando con otras personas en la habitación / área.

The client ’s behavior occurs whenever I stop attending to him/her.

El comportamiento del cliente ocurre cada vez que dejo de atenderlo.

The client seems to do this behavior to upset or annoy me when I am not paying
attention to him/her.

El cliente parece hacer este comportamiento para molestarme cuando no le

estoy prestando atención.

The client seems to do the behavior to get me to spend some time with her/him.

El cliente parece hacer el comportamiento para hacerme pasar un tiempo con

él / ella.

Tangible

tangible de este comportamiento

The behavior ever occurs to get a toy, food, or an activity that the client has been
told he/she can’t have.

El comportamiento se produce para obtener un juguete, una comida o una

actividad que se le ha dicho al cliente que no puede realizar .

The behavior occurs when I take away a favorite food, toy or activity.

El comportamiento ocurre cuando le quito una comida, juguete o actividad

favorita.

The behavior stops occurring shortly after I give the client food, toy, or requested
activity.

El comportamiento deja de ocurrir poco después de darle al cliente comida,

juguete o actividad solicitada.
The behavior seems to occur when the client has been told that he/she can’t do
something he/she had wanted to do.

El comportamiento parece ocurrir cuando se le dice al cliente que él / ella no

puede hacer algo que hubiera querido hacer.

Social (attention /preferred ítems ) Social (atención / artículos preferidos)

The behavior occurs when the client is not receiving attention or when caregivers
are paying attention to someone else.

El comportamiento ocurre cuando el cliente no recibe atención o cuando los

cuidadores le prestan atención a otra persona.

The problem behavior occurs when the client ’s requests for preferred items or
activities are denied or when these are taken away.

El comportamiento problemático ocurre cuando se rechazan las solicitudes del

cliente de artículos o actividades preferidas o cuando se eliminan.

The problem behavior occurs when the caregivers usually try to calm the client down
or involve him/her in preferred activities.

El comportamiento problemático ocurre cuando los cuidadores generalmente

tratan de calmar al cliente o involucrarlo en actividades preferidas.

The clien t usually well behaved when he/she is getting lots of attention or when
preferred activities are freely available.

El cliente generalmente se comporta bien cuando recibe mucha atención o

cuando las actividades preferidas están disponibles sin restricciones.

Social (escape from tasks/activities) Social (escapar de tareas/actividades)

The clien t usually fusses or resist when she/he is asked to perform a task or to
participate in activities.

El cliente generalmente se queja o se resiste cuando se le pide que realice

una tarea o que participe en actividades.

The problem behavior occurs when the client is asked to perform a task or to
participate in activities.
 El comportamiento problemático ocurre cuando se le pide al cliente que
realice una tarea o que participe en actividades .

The problem behavior occurs while tasks are being presented, and the clien t usually
is given a "break" from tasks.

El comportamiento problemático ocurre mientras se presentan las tareas, y al

cliente generalmente se le da un "descanso" de las tareas .

The client usually well behaved when he/she is no required to do anything.

El cliente generalmente se comporta bien cuando no está obligado a hacer

nada.

Automatic (sensory stimulation) Automático (estimulación sensorial)

The problem behavior occurs even when no one is nearby or watching.

El comportamiento problemático ocurre incluso cuando no hay nadie cerca o

mirando.

The client engages in problem behavior even when leisure activities are available.
[10]

El cliente se involucra en problemas de comportamiento incluso cuando hay

actividades de ocio disponibles .

The problem behavior appears to be a form of "self-stimulation".

El comportamiento problemático parece ser una forma de "auto estimulación ".

The problem behavior is less likely to occur when sensory-stimulating activities are
presented.

El comportamiento problemático es menos probable cuando se presentan

actividades de estimulación sensorial .

Automatic (pain attenuation) Automático (atenuación del dolor)

The problem behavior is cyclical, occurring for several days, and then stopping.
 El comportamiento problemático es cíclico, ocurre durante varios días y luego
se detiene .

The client has recurring painful conditions such as ear infections or allergies.

El cliente tiene afecciones dolorosas recurrentes, como infecciones del oído o

alergias.

The problem behavior is more likely to occur when the client is ill.

El comportamiento problemático es más probable que ocurra cuando el cliente

está enfermo.

The client is experiencing physical problems, and when these are treated, the
problem behavior usually goes away.

El cliente está experimentando problemas físicos, y cuando estos son

tratados, el comportamiento problemático generalmente desaparece .

Ejemplos de prompt

I use Errorles learning to keep the child encouraged and from not becoming
frustrated.

I do not allow the child to make a mistake (Errorless learning).

I prompt the child to ensure that he/she get the answer correct.

Prompts and fade prompts

Prompting is a way to teach the child a particular skill so that the child does not get
the answer incorrect. We want to provide a child with prompts for a couple of
reasons:

-The first reason: is that the client will learn the skill the correct way.

-The second reason: is to Keep the client's motivation and self-esteem up. If we
are working on a new skill and wecontinuously get it wrong, our motivation to
perform that skill is going to go way down.
-We use prompts and fade our prompts in a systematic manner, so we do not
promote prompt dependency.

The most common prompts are provided below in a least-to most intrusive
hierarchy:

-Independent: Perform the task without help [no prompt]

-Verbal: Use clear, no repetitive, instructions

-Modeling: Show him the correct response

-Light physical or gesture: You point to the correct answer; or use your eyes to
"gesture" or look at the correct answer

-Physical Assistance: Provide hand over hand assistance so there is no room for
error.

The below prompts are used when you are trying to get a child to engage in a verbal
language:

-Independent: Say the work/works without help [no prompt)

-Verbal: You provide the child with the exact word/words that you want them to
say.

-Faded Verbal : You provide the child with the start of the word/words that you
want them to say.

Generalization

It is important that when we assess we look that the client mastered the skill in:

-different settings: [different rooms, mall, playground, school, restaurant, etc.]

-different material [different puzzles, books, movies, TV programs, kitchen utensils,

etc.]

-different people: [parents, grandparents, siblings, uncles/aunts, friends, teachers,

people in the community]