A Pilot Study on Professional Documentation: Do We Write From a Strengths Perspective?

Purpose: There is growing evidence supporting the use of strengths-based practices when serving families. The purpose of this study was to examine the use of strengths-based approaches in the context of written professional documentation. We specifically explored whether or not interdisciplinary clinicians in one university-based medical center clinic write from a strengths perspective (e.g., writing focuses on abilities rather than on deficits) when documenting child behavior in autism diagnostic clinics.

Method: We gathered narrative-based writing samples (a total of 299 phrases) from 20 patient reports. Using a coding system developed by the research team (intraclass correlation coefficient = .801 on final definitions and coding system), we analyzed the extent to which interdisciplinary clinicians included strengths-based language (e.g., language that emphasizes a person's strengths rather than limitations) in their written documentation. An independent researcher coded a random sample (20% of entire sample) of the data to document reliability of the coded data (97% interrater agreement).

Results: Our findings indicated that clinicians in our study used deficit-based language significantly more than neutral and strengths-based language in written documentation.

Conclusion: This preliminary evidence suggests a need to reflect upon our own understanding of strengths-based practices and the way professionals write about children in clinical documentation.