Assessment tool helps evaluate chart notes

By David Lewellen
Vision editor

When Carolanne Hauck and Beverly Beltramo couldn’t find a tool to assess the quality of spiritual care notes, they developed one of their own.

No consensus has yet developed around best practices for charting, and “just because we think we’re doing it well doesn’t mean we are,” Beltramo said. But last year, she and Hauck were separately looking for a more empirical method when they connected as part of an NACC work group about electronic medical records. Together they developed a matrix that rates a chaplain’s note in three broad categories: spiritual assessment, implications for care, and narrative. (A sample note, and the matrix assessment of it, are shown below.)

In active use, Hauck said she has found that “chaplains tend to put in too much rather than not enough.” Beltramo said, “Narrative is a challenge, making sure that it says what it needs to say while still being reasonably brief.”

Beltramo used the matrix in monthly department meetings, choosing a note at random and leading a discussion over where it fell in the various boxes of the grid. (The author of the note has the option of remaining anonymous during the discussion.) Hauck has used it in training and in discussions of what makes a good chart note; it serves as a concrete example for people for whom charting is a growing edge for what their peers see as quality work. “We’re all on this journey together,” she said.

Hauck is the director of chaplaincy care and education at Lancaster General Health in Pennsylvania. Beltramo is currently chief mission officer at St. Joseph Mercy Oakland in Michigan.

Practically, a good documentation that hits all the necessary points can be invaluable for a colleague making a follow-up spiritual care visit, and it can also help doctors and nurses. “It can be long and detailed, but not long and rambling,” Beltramo said. “Sometimes there’s a lot of nuance in what we hear from the patient, and if we can capture that,” others are grateful.

Hauck said that frequently, palliative care notes are longer, “because the other members of the team need more. … We’re willing to do what’s most helpful to the staff.”

However, both chaplains sounded cautions about diving too deeply into the medical portion of a chart. “You could spend a day reading a 40-page chart and not have the depth of understanding,” Beltramo said; more often, the chaplain can learn the essentials by talking to the nurse on duty. “She really knows the patient and has a clue how we can be the most helpful,” Hauck said.

In noting outcomes and results, Beltramo cautioned that “in a 20-minute visit, the patient’s not going to be, ‘Oh, I’m happy now.’” Chaplains “need to learn to be OK with that. Sometimes it’s enough that you’re present to whatever it is.”

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Chaplaincy Care Note

Family requested post-mortem visit following death of pt.
Assessment
Daughter and granddaughter actively grieving: reminiscing about patient’s life and meaningful family experiences. Family actively supporting one another in helpful ways. Family is Mennonite (Willow St Mennonite Church) and find comfort in their faith at this time.
Goals for Spiritual Care
The family will have the opportunity to spend time with deceased patient in a way that is meaningful for their grief process.
Interventions
Encouraged and affirmed family’s expressions of meaning for the deceased’s life.
Responded to family’s request for scripture and prayer.
Provided guidance about funeral arrangements, info on grief resources, and education about grief process.
Outcomes
Family found meaning and peace of mind spending time with deceased and saying goodbye. Family completed needed tasks and expressed readiness to leave.
Family contact information (son, Brian, 555-5555) and Snyder Funeral Home number given to nurse. No f/u needed at this time.

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