Published on: September 3, 2025
A NABITA Tip of the Week by Tim Cason, M.Ed.; Vice President, NABITA; Senior Consultant, TNG
This week, we are building on our previous discussion of why documentation is essential for BIT/CARE Teams. In this installment, we introduce practical strategies, drawing from industry guidance and additional best practices to help your team document effectively, consistently, and ethically.
NABITA has developed industry standards to guide practitioners in establishing and improving their BIT policies, processes, and procedures. We have also published Tips of the Week with further insight into each Standard. In our Tip of the Week on Standard 18: Recordkeeping, we offer a discussion regarding documentation and emphasize using an electronic data system to track referrals, risk ratings, case notes, interventions, and communications consistently across all cases. We also recommend maintaining an accessible, searchable database accessible to all team members, using behavior-focused, neutral language with observable detail and direct quotes, and adopting structured categories such as risk level changes, contact attempts, and referral sources to enable reliable data reporting and quality assurance. In addition to this previously published guidance, the following strategies can strengthen your team’s documentation practices.
First, conducting periodic records audits strengthens the quality, consistency, and defensibility of BIT/CARE team documentation. Two recommended approaches include a quarterly individual record review and a semiannual group documentation audit. The quarterly individual record review focuses on routine quality control by having the chair review a selection of BIT/CARE Team records to catch inconsistencies or gaps early. The biannual group documentation audit involves a collaborative review of anonymized or closed cases by the full team to identify trends, reinforce expectations, and support shared learning and continuous improvement in documentation practices. Together, these approaches enhance both individual accountability and collective team performance.
Second, we recommend that each team document a consistent set of case elements. These include the initial risk level assigned, any changes in risk level throughout the duration of the case and the rationale for each, all actions taken with or on behalf of the individual, such as communications, referrals, consultations, assessments, and interventions, and all unsuccessful attempts to contact the individual or relevant parties such as guardians, supervisors, or referral sources.
Third, use structured note categories and templates. Standardized headings such as BIT Meeting Summary, Phone Call – Faculty/Staff, Email – Student, and Appointment – Missed help ensure consistency and make it easier for team members to review cases, generate reports, and maintain continuity over time.
Fourth, use third-person, behavior-focused, and non-judgmental language to ensure documentation remains objective, accurate, and defensible. Writing from the perspective of a neutral, detached observer helps maintain professionalism and keeps the focus on what was observed or reported, rather than on personal feelings, assumptions, or interpretations. For example, teams should describe the specific behaviors or statements, such as “The individual stated they were not going to leave until someone listened” or “Staff observed the individual pacing and repeating questions in a raised voice,” rather than writing “I felt threatened,” or “He was clearly unstable.” This approach reduces bias, improves clarity, and ensures that records are consistent and reliable. It also reinforces the credibility of the team and encourages fair, ethical decision-making by emphasizing facts over feelings and observations over interpretations.
Finally, ensure that all team members have access to and training on the documentation system. BIT/CARE Team work often involves multiple disciplines, and every member needs to know how to access case files, enter information appropriately, and follow documentation standards. Ongoing training reinforces best practices, ensures compliance, and builds collective confidence in the recordkeeping process.
By implementing these practices, teams enhance the quality and consistency of their casework, reduce bias, improve defensibility, and build a resilient system that can adapt over time.
Build your knowledge with NABITA’s BIT Standards and Best Practices, or enhance your documentation skills through our BIT and Case Management Recordkeeping and Documentation Workshop.