Traits, States, and Diagnosis-We don’t use them.

Why They Matter — and How They’re Misused

In ABA documentation, it’s critical to describe what you observe, not what you assume.
Words that refer to traits, states, or diagnoses often cross that line and can unintentionally reflect bias, judgment, or medical interpretation, which falls outside the RBT’s role.

Traits

Definition: Stable characteristics that describe personality or temperament (e.g., “lazy,” “stubborn,” “shy,” “defiant”).
Why it’s a problem: Traits imply fixed qualities rather than observable behaviors.
Example:
❌ “Client was defiant during table work.”
✅ “Client pushed materials away and said ‘no’ when the demand was presented.”

States

Definition: Temporary emotional or physiological conditions (e.g., “anxious,” “tired,” “angry,” “frustrated,” “bored”).
Why it’s a problem: States interpret internal experiences that can’t be directly observed or measured.
Example:
❌ “Client was frustrated when asked to clean up.”
✅ “Client yelled and threw two toys when asked to clean up.”

Diagnoses

Definition: Clinical or medical labels (e.g., “autistic behaviors,” “ADHD moment,” “OCD tendency”).
Why it’s a problem: Diagnoses are determined by qualified professionals (not RBTs) and should not be used as shorthand for behavior.
Example:
❌ “Client had an autism meltdown.”
✅ “Client dropped to the floor, covered ears, and cried for 3 minutes after loud noise.”

Objective vs. Subjective Notes — Quick Check

Choose the option(s) containing non-objective “trigger” wording (feelings/judgment, vague praise, or conjunction-heavy run-ons). Then click Grade.

Q1. “Sarah was frustrated with her task but eventually got it after I encouraged her.”




Q2. “Mark did really well today and had fun with his peer during block play.”



Q3. “Client completed 4/5 independent responses in the matching program and required one verbal prompt.”


Q4. Which version is objective and concise?


From the Behavior Analysis Services Coverage Policy (Florida Medicaid)

“Session notes must be signed and dated by the rendering practitioner and parent/guardian. Session notes must include:
– Date, time, and duration of services
– Maladaptive behaviors observed during the session
– The replacement/compensatory skills targeted during the session
– Description of the recipient’s response to the treatment interventions
– Protocol modification, changes to goals/objectives, and/or therapist directions provided during the session, if included
– Explanation if recipient’s parent or guardian is not present during BA service delivery
– Participants, including observers, teachers, parents, or other healthcare providers if present.”
Florida Health Admin+1

Why this matters: This shows Florida Medicaid explicitly requires session notes to contain observable behaviors, responses to interventions, data-driven targets, and changes made — aligning with objective documentation practices.

Some state links to Documentation Standards

These links were last verified on 11/12/2025. Because state Medicaid standards are frequently updated, we cannot guarantee all links remain active or reflect the most current policy. If you encounter a dead link, wrong document, or unclear standard, please notify the Admin for BCBA Made at admin@bcbamade.com
Use of these materials is for educational reference only. Providers must refer to their state’s official Medicaid/agency website for the definitive policy.

California- BHIN-22-019: Documentation Requirements for all SMHS, DMC & DMC-ODS services (DHCS) Published April 2022. (DHCS)

Texas-Texas ABA Services: Documentation & Medical Necessity (Aug 2025) (Provider Express) Published August 19, 2025.

Florida Rule 59G-1.054 Recordkeeping & Documentation Requirements (FL) (Florida Health Admin) Florida Administrative Rule, last updated ~8.5 years ago.

New York- Session Notes & Progress Note Requirements (NY Medicaid) (oms.nysed.gov) Revised July 13, 2015.

North Carolina- North Carolina Department of Health and Human Services – Record Management & Documentation Manual (NC DHHS) Updated July 8 2025. (NC DHHS)

Georgia- Georgia Department of Community Health – Provider Manual (Medicaid) / Medical Record Documentation Standards (CareSource) Policy effective October 1 2024. (CareSource)

Colorado Colorado Department of Health Care Policy & Financing – State Behavioral Health Services Billing Manual (includes documentation standards) (HCPF) Effective July 1 2025. (HCPF)

From the Medical Records Standards (via Sunshine Health, a Florida Medicaid plan)

“All entries must include the name and profession of the provider rendering services … All entries are dated with the dates of service … within two business days from the date and time of service … All records must contain a description of services rendered, disposition, recommendations, instructions to the patient, evidence of whether there was follow-up, and outcome of services.”
Sunshine Health

Why this matters: While not ABA-specific, this supports broader documentation compliance expectations: timely, signed, detailed, complete — which help reinforce the need for objective, measurable language in notes.

From a general behavioral health documentation guidance (federal/Medicaid level)

“Documented services must:
• Meet that State’s Medicaid program rules;
• … reflect active treatment;
• Be complete, concise, and accurate, including the face-to-face time spent with the patient … be signed and dated … and be maintained … available for review.”
Centers for Medicare & Medicaid Services

Why this matters: It emphasizes that documentation must reflect “active treatment” (i.e., measurable behavior change, not vague or passive wording) — supporting your lesson’s objective vs. subjective distinction.