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Session Notes

Session notes document each therapy session and are required for billing, clinical tracking, and team communication.

Why Session Notes Matter

“Gathering accurate and consistent data during each session allows us to monitor progress, identify patterns, and adjust treatment strategies to better meet the unique needs of each client.”

Every data point helps ensure effective, individualized care.

Documentation Requirements

During the Session

  1. Open HiRasmus and “Start Session” when face-to-face with client
  2. Collect data on all programs throughout the session
  3. Document behaviors, responses, and progress as they occur

Completing Session Notes

  1. End session on HiRasmus with the correct end time
  2. Finalize notes before leaving the client’s location
  3. Click the “Send Now” blue button to sync with Aloha
  4. Sign provider signature with your finger

Timeline

  • Session notes must be finalized same day as the session
  • Do not leave documentation for later — this delays billing

What to Include

Required Elements

  • Programs and targets worked on
  • Data collected for each program
  • Client response and engagement level
  • Any challenging behaviors that occurred
  • Reinforcement used
  • Notable progress or regression

Clinical Feedback for Parents

After each session, provide a brief summary to the parent/caregiver:

  • Skills worked on during the session
  • Reinforcement that was effective
  • Any challenging behaviors
  • Use positive and encouraging language

Team Communication

After completing session notes, send an update to your Hive team via Microsoft Teams:

  1. Open Teams app
  2. Go to client’s Hive team chat
  3. Send audio or video message (preferred over text)
  4. Include your BCBA and other therapists on the case
  5. Keep under 5 minutes

What to Cover

  • How the session went overall
  • Any major behaviors or changes
  • Questions for the team
  • Collaboration opportunities

“There is never too much communication!”

Software Integration

HiRasmus → Aloha Flow

  1. Start session in HiRasmus when face-to-face
  2. Collect data throughout session
  3. End and finalize session in HiRasmus
  4. Click “Send Now” — this automatically converts to Aloha
  5. Verify appointment shows as “completed” (closed dot) in Aloha

Important Notes

  • Do NOT “Start Session” for indirect or drive time appointments
  • If scheduling changes occur, update Aloha immediately
  • Every Friday, review your week’s schedule in Aloha day-by-day

Common Mistakes to Avoid

MistakeWhy It Matters
Starting session late in appInaccurate billing, data gaps
Leaving notes incompleteDelays payroll, incomplete records
Forgetting provider signatureSession may not be valid
Not syncing to AlohaHours won’t appear on timesheet
Waiting until later to documentMemory gaps, inaccuracies