By Mary M. Toole
At our hospital, chaplains for many years were not allowed to write in patients’ charts. For example, when a doctor had made a referral to pastoral care, or if there was a significant case, chaplains would ask the patient’s nurse to document the presence and support of pastoral care. Like some other hospitals, every admitted patient was seen by a chaplain within 24 to 48 hours of their arrival. The chaplains as a group designed the paper assessment forms that were maintained in the pastoral care office. Updates were noted on these forms. But electronic medical records would be the start of our chaplains documenting in the patient’s chart (standard 304.6).
The directors of the pastoral care departments from the many acute care facilities within our organization met, and by reviewing samples, designed the screens that chaplains would use in the EMR system. As this was occurring, a committee of chaplains was formed at our facility to design a paper version of the main screen in preparation for EMR. We completed the assessment form for every patient and kept them in unit binders in the staff office. Chaplains were required to update the assessments after follow-up visits. The committee of chaplains completed a regular review of the assessments with a report indicating areas needing improvement. We shared a general review and observations with the staff without mentioning chaplains by name (standard 305.5).
As the time came to go live with EMR, our chaplains were looking forward to actually documenting in the patients’ charts (standard 305.1). We started by only using check-offs in all areas. Our assessments consisted of the following areas: clinical encounter, religious encounter, sacramental encounter, patient’s spiritual encounter, family spiritual encounter, and advanced directives.
Each area contains multiple items for check-off responses; many of these check-offs allow for a comment to be typed. For instance, in “patient’s spiritual encounter” there is an item grief. If the chaplain checked off any of the options for grief, a comment or brief explanation could be typed. If the chaplain marked “demonstrates grief often,” the comment section could indicate the source of the grief; e.g., husband died last month. The completed grid of check-offs is inserted into the Notes section of our EPIC system, making the assessment viewable to all members of the patient’s care team.
As we began charting in EMR, we were not writing narrative assessments because we needed further training. Most helpful to us was the two-part NACC audio conference held June 5 and 12, 2014 by Gordon Hilsman titled “Summary Point Charting for Interdisciplinary Effectiveness,” and “Part II, Fashioning Summary Points.”
A chaplain attending a conference brought back Chaplaincy Taxonomy by Advocate Health Care, which provided a list of suggested words to use for intended effects, methods, and interventions while writing a narrative statement.
To assist in writing quality narrative statements, all chaplains submitted a narrative statement for review. These statements were typed on one sheet of paper without identifying the chaplain. As a department, we discussed what was good/bad and how they could be improved. We then settled on five questions that should be answered in writing all narrative statements:
1) Why did you make the visit (referral, initial visit, crisis, follow-up)?
2) What was the patient/family issues that were discussed (specifics not necessary)?
3) What interventions were provided?
4) Patient/family response to the interventions?
5) What is the future plan?
The statements are to be brief and patient/family oriented (standard 303.8).
We encouraged chaplains to follow this process in writing narrative statements in the Notes section of the EMR, making the assessment visible to all members of the patient’s care team. We had our own quality review using our previous process. During this review, chaplains began to identify their narrative statements as they were discussed, sharing specific facts behind their narrative writing to help improve their writing skills.
Our staff chaplains’ next step will be to ask our interdisciplinary teams for input (standard 305.2). Possible questions, taken from a presentation by David Lichter at the NACC conference, are: Do you read our chart notes? Do you find the notes valuable to your work? What about the note is meaningful to you?
This is an ongoing learning process for all members of the department, and together we will continue quality review of our documentation.
Mary M. Toole, BCC, is a staff chaplain at St. Francis Hospital, the Heart Center in Roslyn, NY.