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Home » Vision » July-August 2017 » Chaplains need skill and confidence to write effective chart notes

Chaplains need skill and confidence to write effective chart notes

By Gordon Hilsman

Many chaplains are quietly apprehensive about actually joining an interdisciplinary team. They have many questions: Do I have the time to dedicate myself to what it takes to join that team? Could I actually become a member of that particular team? Do I even want to practice in that way?

True membership is not merely being named on a list somewhere, or being assigned to that team by your director, or being greeted warmly by the team members. Actually contributing on a frequent basis to the core work of that team, including notes in a patient’s medical record, is what constitutes belonging.

And what often keeps chaplains on the periphery is lack of confidence — confidence in oneself, one’s pastoral identity, and one’s ability to stand with other team members as valued professionals able to make regular contributions to the primary work of that team and hospital unit. In my recent book, Spiritual Care in Common Terms, I use the following story to illustrate this difficulty.

A management development program being used by a medium-sized healthcare system asked employees several pointed questions in order to give feedback to department directors on their leadership. One of the questions to staff members was, “Do you believe that your work contributes to the mission of this healthcare system?” The spiritual care director was more than appalled when several of the questionnaires from her chaplains answered the question flatly, “no.” They did not see their care of patients’ inner world, ultimate concerns, and challenges to their very core making a contribution to their healing. “Why is this hospital paying you then?” she asked the entire staff. A great teaching moment had erupted. If spiritual care does help patients heal, then its caregivers’ notes belong in the charts. If not, then why are they working there?

Hospital chaplaincy has been changing rapidly for over a decade. What may be required for employment now may be quite different from what was needed for chaplaincy certification. It is easy to lose confidence when some tasks, such as charting, are expected to relate effectively to an interdisciplinary team more than they were even 15 years ago.

Gaining confidence is however, not the core problem. Confidence without competence is dangerous. It is sometimes easily recognized by astute team members as adolescent bravado, foolhardiness, and pretentiousness. If there is no meat to interactions with IDT staff members, cheery posturing will soon fade. Inspiring confidence in other staff members about your effectiveness will likely require observable expertise.

It is easy to lose confidence when some tasks, such as charting, are expected to relate effectively to an interdisciplinary team more than they were even 15 years ago.

How, then, does one develop competence in team communication? The same way one gains expertise in athletics, music, nursing, and other professional fields — with practice and direct feedback from a mentor and/or peers.

If you want to continually improve your concise recording of patient narratives and useful descriptions of patients’ human spirit situations, reach out to some colleagues and show your chart notes to one another for feedback. If that isn’t done in your department, form your own group.

Three things to avoid when you do that: processing a single note too much, too deeply or too personally; allowing yourself to get too hurt by critiques of your notes; and defending a note you are presenting rather than exploring it. This is an art you are trying to improve. Art improves with practice and feedback. Make up your mind to enjoy peer interactions about your notes, get what you can from it, and commit yourself to learning as a delightful experience.

Gordon Hilsman, BCC, is an ACPE supervisor and the author of Spiritual Care in Common Terms.

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