By Fr. Bryan Lamberson
Years ago as a fledgling chemical dependency counselor, I was taught, “If it’s not written down, it never happened!” No exceptions. Though that frame of mind may have been informed more by legal than clinical concerns, the medical record is still the single most useful tool in communicating the interactions caregivers have with their patients. Entirely electronic medical records can improve efficiencies, reduce expense, and most importantly, improve patients’ care. However, far from being the magic bullet that may have been initially envisioned, EMRs present both challenges and opportunities never imagined in the good old days of paper charting.
I minister in a merged comprehensive health system (Catholic/Jewish/academic). The considerable trials of integrating our individual heritages and cultures into a single, highly functional system seem to pale in comparison to the challenge of us all getting on the same page for electronic charting. Ideally, we could communicate critical medical information across the many hospitals, physician groups, clinics, primary care centers, specialty institutes, and home health agencies that make up our organization. That hasn’t yet happened. One hospital recently attempted the transition to a fully electronic medical record. The initial results were reminiscent of the online rollout of the Affordable Care Act. As a result, full implementation in our other facilities has been postponed for perhaps another three years. For the time being anyway, the seamless communication among providers at different locations predicted by the IT designers are still an unrealized dream. We have not retired our fax machines.
But paper charting in my hospital also has problems. When I anoint a patient with the Sacrament of the Sick, this is what I have to do afterward: 1) Hand-write a progress note to that effect in the hard chart; 2) Affix an adhesive sticker stating “This patient has received the Sacrament of the Sick” at the end of the progress note; 3) Write a note in the electronic medical record, choosing from drop-down menus of available pastoral interactions; and 4) complete a 3×5 index card documenting the encounter, to be filed in the chaplain’s office. If no family members are present at the time of the anointing, I’ll leave my business card with a note that “Mrs. So-And-So received the Sacrament of the Sick on this date and time.” The documentation frequently takes longer than the administration of the sacrament itself.
Also, the IT designers lack the insight into our discipline (or they never asked) to offer a comprehensive drop-down EMR menu that reflects what we as chaplains do. For example, our EMR system has no menu choice for the Sacrament of Reconciliation. The closest thing is “Spiritual Direction,” an indication that the menu was written long before the current significance of clinical focus on length of stay. Neither are there choices that reflect the importance of very human pastoral interactions such as encouragement or humor.
In one of our other hospitals it’s somewhat simpler: No progress note or index card is required, since I provide only emergent care at this campus and have not received training in the EMR. I chart nothing. Placing the sacramental sticker on the front of the hard chart, on which I write the patient’s name and my own and the date the sacrament was administered, suffices. In one important sense this seems preferable, since everybody who picks up that chart will see the sticker, similar to a DNR sticker. I don’t want my phone ringing at 3 a.m. for an anointing I’ve already done and documented.
Since the full implementation of EMR systems seems a way off for some of us (let’s not throw away our favorites pens just yet), I would suggest that as long as hard charts are used, the “sacrament sticker” be placed on an empty section of the face sheet, since that’s where clinical staff will go to look for next-of-kin phone numbers if the patient takes a turn for the worse.
Regardless of the EMR system used or the trials that systemwide implementation pose, best practices will remain academic if the observations and interactions we document are not used as part of a well-functioning multidisciplinary team. Plainly put, what good are our notes, handwritten or electronic, if nobody reads them?
Fr. Bryan Lamberson, BCC, is a chaplain at Sts. Mary and Elizabeth Hospital in Louisville, KY.