Build one authoritative, connected record
UK-SBA registrants are expected to document work sufficiently for review, accurate provision and handover. A useful case record has distinct but connected categories: enquiry and intake; identity, authority, agreement and consent; assessment and baseline; goals, plans and revisions; session notes; structured data; reviews and decisions; material communications; restricted safeguarding, incident and complaint records; billing; and closure or handover.
The records need not all live in one database, but the practice must define the source of truth for each category and how information moves into it. Email can transport a message, but material decisions, consent changes, risks, advice and programme changes should enter the controlled case record.
Make session notes intelligible and proportionate
A practical note may include date, time or duration, setting, author, people present, relevant active plans, material context, work undertaken, important observations, a reference to structured data, deviations, consent or assent issues, safety matters, decisions and follow-up. Do not force empty prose into every heading.
Separate direct observation, third-party report and professional interpretation. Attribute reported information, identify hypotheses as hypotheses and avoid pejorative language. Write soon enough that memory is not doing the work. HCPC and GMC standards are useful comparators on prompt and contemporaneous records, but they do not automatically bind behaviour analysts who are not regulated by those bodies.
More text is not necessarily better. The narrative should give context that data alone cannot provide. Raw data should identify what was measured, how, when and under what conditions. The visible chain is: observation or measurement, data pattern, review, decision, plan revision, later measurement.
Preserve history and support access
Do not silently rewrite past notes. Use a correction, addendum, audit or version history that shows what changed, who changed it, when and why. A disagreement with professional opinion is not always an objectively inaccurate fact; correct factual errors where appropriate while retaining a fair record of changed conclusions.
Recordings need separate consent and tighter controls over purpose, device, storage, access, retention, secondary use and third parties. Restrict access by role and case. Use meaningful identifiers and metadata, including client or case ID, document type, author, service date, effective date, version and status. Define active, archived, held, due-for-review and deleted or anonymised states.
Design for handover and audit
Before a practitioner leaves, identify active cases, current plans, outstanding notes, significant decisions, reviews, safeguarding or complaint issues, information held outside the main system and access to revoke. Periodically sample notes for author, service date, prompt completion, plan context, data link, decisions, consent or safety issues, factual language and handover usefulness. Repeated problems may be a form or workflow issue rather than an individual failure.
References
- UK Society for Behaviour Analysis, Code of Ethical and Professional Conduct, June 2026Principles 6 to 8: consent, recording, review, plans, notes, data, handover and confidentiality.
- ICO, Records management audit framework: Record creationRecord creation, identification, classification, metadata and sampling.
- HCPC, Record keeping expectations; GMC, Good medical practice, Domain 3Prompt, accurate, proportionate records. These are professional comparators, not automatic rules for all behaviour analysts.
- GMC, Recording decisionsContinuity, decisions, recordings and consent. Comparator only.
- ICO, Records management: Access; A guide to subject accessRole-based access and reasonable searches.
- ICO, Storage limitation; Disposal and deletionReview, retention, deletion, backups and third parties.