By Austine Duru
The patient is the focus of all forms of patient care. This fact is not lost on chaplains and healthcare providers who are challenged daily to provide the best care possible utilizing all resources at their disposal — one of which is documentation. A common phrase in chaplaincy circles is “If it is not in the chart, it did not happen.” Technology has facilitated electronic medical records as a standard practice. However, the art of crafting well-written chart notes is still very relevant, even at a time when medical records or patient charts are going digital.
Unfortunately, research into the effectiveness of documenting chaplain interventions in medical records (paper or electronic) is not as robust as research in other areas of chaplaincy care. A few key articles sum up the ongoing debate and development in this area.
Available early research on this topic focused on making the case for why chaplains should document their intervention. Notable among this earlier work is Rob Ruff’s “‘Leaving Footprints’: the Practice and Benefit of Hospital Chaplains Documenting Pastoral Care Activity in Patients’ Medical Records” in the Journal of Pastoral Care. Ruff, a chaplain, aims to establish a contextual framework to justify the relevance of charting. This coincides with a broader push across major chaplaincy organizations to include professional chaplains as integral members of the healthcare team. He identified three key reasons for chaplains to document their work: (1) Chaplains are integral members of the interdisciplinary care team. (2) Documentation will help create more visibility for the chaplain as a professional. (3) Documentation of spiritual interventions is proof of compliance with regulatory requirements by the Joint Commission to provide for the spiritual needs of all patients.
Ruff uses the SOAP (subjective information, objective information, assessment, and plan) method of documenting patient visit. This became a predominant model in chaplaincy circles for several years. This work is remarkable in its effort to encourage chaplains to adopt a stance of curiosity about their work — an initial attempt at evidence-based spiritual care.
A provocative article jointly published by Roberta S. Loewy, Ph.D., and Erich H. Loewy, M.D., in 2007 titled “Healthcare and the Hospital Chaplain” generated strong reactions from professional chaplains and healthcare providers alike. This article stirred the waters, and challenged the basic identity of professional chaplains and their role in the care of patients. At the root of Roberta Loewy (associate clinical professor) and Erich Loewy’s (professor emeritus) contention are patient rights to privacy and confidentiality, with a good dose of skepticism about what they called the “claims and assumptions of those involved in chaplaincy.”
Several articles have emerged since to reinforce the role of professional chaplains as an integral part of the interdisciplinary healthcare team, but with a critical eye to some of the concerns highlighted by Loewy and Loewy. One of these works merits our attention here.
Rabbi Rafael H. Goldstein and co-authors Deborah Marin and Mari Umpierre in 2011 published a research work in the Journal of Health Care Chaplaincy titled “Chaplains and Access to Medical Records.” The report studied how chaplains gain access to patient records and document their work across 44 large hospitals in the United States. Their findings support the practice of documenting chaplaincy interventions in patient records. It also led to an institutional decision at the author’s hospital to require chaplains to chart their interventions in patient record without extra credentialing, and pastoral care leaders were invited to help design, develop and pilot electronic medical records. This is a remarkable illustration of how research can support the practice of professional chaplains. This article is commercially available for a small fee at Taylor & Francis Online. A more thorough review could also be accessed at the ACPE Research Network.
David McCurdy’s “Chaplain, Confidentiality and the Chart” is another substantive article on this topic. While not a research project, it offers an ethical dimension on the challenge of charting in chaplaincy interventions in patient records. In reference to Loewy and Loewy above, McCurdy offers a nuanced view on documentation, patient rights, and confidentiality, and suggests it is vital for chaplains to reflect on how they use and share protected health information. McCurdy’s extended examination of confidentiality lays the foundation for a normative framework that chaplains and institutions may use to address documentation and confidentiality issues. The principles and value priorities that follow may inform chaplains and institutions’ approaches:
- Identify and prioritize the values and interests at stake, putting the patient’s interests first.
- Respect and appreciate the potential sacredness in what the patient communicates and document accordingly.
- First, do no harm.
- Inform patients that chaplains document and are open to discussing what this means.
- Apply the need-to-know test thoughtfully.
- Ask “What would I want — and not want — disclosed to the health care team if I were this patient?” (McCurdy, 2012).
Another article, “Measuring Spiritual Care with Informatics” by Burkhart and Androwich, offers a perspective from nursing research around documenting spiritual care. Their aim is to apply the theory of informatics to aid in the development, design, execution, and evaluation of chaplain interventions. In the July/August 2009 issue of Vision, Burkhart shares a case example from Loyola University Health System in an article titled “Informatics: Capturing and Measuring Spiritual Care.”
Today, more data is available, coinciding with the push to capture an accurate and complete record of patient care. Major chaplaincy organizations have adopted documentation as an important standard of practice. With documentation comes the possibility to review, measure, and improve the quality of care. More research by professional chaplains and collaborators is needed to support the requirement for chaplains to share their encounter and intervention with the interdisciplinary care team, while focusing on the specific need of each patient.
Austine Duru, BCC, is regional director of mission, ethics, and pastoral care at SSM Wisconsin.
References:
Association for Professional Chaplains (2009), Standards of practice for professional chaplains in acute care settings. Accessed June 2015.
Burkhardt, L., & Androwich, I. (2009), Measuring spiritual care with informatics. Advances in Nursing Science, 32 (3), 200-210,
Goldstein, H. R., Marin, D., & Umpierre, M. (2011). Chaplains and access to medical records. Journal of Health Care Chaplaincy, 17(3-4), 162-168.
Loewy, R. S., & Loewy, E. H. (2007). Healthcare and the hospital chaplain. Medscape General Medicine, 9(1), 53. Accessed June 2015.
McCurdy, David B. (2012) Chaplain, confidentiality and the chart. Chaplaincy Today 28(2).
Ruff Rob A. (1996), Leaving footprints: The practice and benefits of hospital chaplains documenting pastoral care activities in patients’ medical records, Journal of Pastoral Care 50, (4), 390f.
