By Marika Hanushevsky Hull
Like most of us called to chaplaincy, chaplain interns in the CPE program are ready and open to care for patients, and see electronic charting only as a necessary evil. But in teaching CPE students about electronic charting, I try to emphasize two things: that charting is part of professional interdisciplinary practice, and that charting is part of the continuing spiritual care of the patient in the permanent medical record.
Some of the essential and practical aspects of charting that are covered in CPE training are: the meaning and ownership of the medical record; the legal limits of charting, and the legal implications of charting and not charting; avoidance of medical terminology; avoiding legal snares; the reasons for charting and criteria for what not to chart; tips for effective charting; conciseness and distinguishing objective from subjective data. In this article I will primarily touch on the reasons for charting and on conciseness in charting.
CPE provides training for charting according to the objectives outlined in the ACPE handbook and the Common Standards of our profession. Although different forms and formats are used in different institutions, the kind of information that is communicated is similar. Like texting, Facebook, or instant messaging, electronic charting has its own unwritten rules for format and type of information. The most important bits of information are the date, time, and duration of the visit, the patient’s religious preference, the reason for the visit, and comments.
Date, time and duration are set. Religious preference is straightforward if the patient is of a mainline denomination or faith tradition. Many patients who say they have no religious preference, might, after conversation with the chaplain, describe themselves as spiritual but not religious, or of no particular religion. For these patients one suggestion is to enter: “Religion not specified.” It is a respectful way to leave the conversation open for the patient, and to signal to other spiritual care providers that the patient is open to discussion of spiritual needs or concerns.
The reason for the visit is a tricky area to maneuver. The information on the chart is permanent. If a patient or family member should request a copy of the medical record, would they want “grief,” “relationships,” “God,” “faith and hope,” “discouragement” to be part of their permanent record? Is it best to maintain the confidentiality of the conversation, and to signal the need to another team member in the record only with the patient’s permission, or if the chaplain feels that it is necessary for the care of the patient? This is a pastoral question and decision. Any comment that could possibly shame the patient should not be made in the record. Of course, mandated reporting of child or elder abuse or suicidal ideation do not fall under discretionary documentation, and must be reported by the chaplain according to their hospital protocols and policies.
What to say and how to say it is also an area of concern. The space for comments on the electronic chart can be a choice of boxes to be checked or a drop-down menu with limited space for typing. Even though there may be no technical limit on the words you can write in the box, the electronic rectangle itself gives an instant visual limit. If another team member clicks the note box and has to scroll down too far, you will lose your reader. Twenty-five words or so, or whatever will fit easily into the space, is a good goal. Typing in all caps is easier, so that you do not have to think of upper and lower case. Keeping abbreviations to an absolute minimum also helps to make the message clear. For example, “PT” for patient, “CH” for chaplain, and “DR” for doctor are easily recognizable.
A chart note is also a way to speak to a particular audience, whether it is the nursing supervisor, the physician, the occupational therapist, the next chaplain on call, or even the patients themselves or their families. Most importantly, it communicates the singular contribution of spiritual care to the patient’s healthcare team. Charting is a way for chaplains to hone their pastoral practice and assessment framework, to provide a brief time for reflection on the visit, to choose whom the chaplain is “messaging.”
Charting is not just a chore at the end of a visit or an already long day. It is an integral part of pastoral practice in healthcare settings. It is a way for chaplains to continue to care for the patient in the permanent record. Professional practice as guided by the objectives and outcomes in CPE training and as required in the Common Standards of chaplaincy is an ally and an aide to pastoral care in the patient record.
Marika Hanushevsky Hull, BCC, is a chaplain at St. Anne’s Hospital in Fall River, MA, and a supervisory candidate at the Holy Family Hospital CPE Program in Methuen, MA. She conducts supervisory classes at St. Anne’s.
