Gordon J. Hilsman, Spiritual Care in Common Terms: How Chaplains Can Effectively Describe the Spiritual Needs of Patients in Medical Records, 2017, Jessica Kingsley, London and Philadelphia
By Marilyn Williams
Gordon Hilsman’s “Spiritual Care in Common Terms” is essential reading for both beginning and seasoned healthcare chaplains. Although the subtitle implies that it is a how-to manual regarding medical record documentation, the book is much more than that. Hilsman has written a comprehensive, in-depth treatise for understanding and articulating a patient’s spiritual needs and spirituality from a humanistic perspective. As such, his book is not just for chaplains in this era of holistic, person-centered care, but for physicians and other clinicians.
“Capturing the soul,” or the person’s unique essence, is the goal of writing chart notes, Hilsman writes. However, first he argues for the importance of recording the “intangible,” the human spirit of the patient. Secondly, Hilsman explains a humanistic theory of four primary arenas of spirituality: personal, interpersonal, transcendent, and communal as the means of eliciting and hearing the patient’s story. He asserts that what happens in these arenas “constitutes spiritual needs, the content of spiritual care, and recording it in the medical record.”
Hilsman identifies the most common spiritual needs of patients that he has seen in more than 40 years as a CPE supervisor based on four axes: emotional support, major loss, religious/spiritual practice, and referral needs. After a consideration of these spiritual care needs, he describes fashioning specific goals of spiritual care to address them.
For the actual format of the chaplain’s clinical note, he begins with this quote from a medical resident: “This one chaplain guy writes the same thing every time! What’s the sense in that?” My guess is that many chaplains have experienced the same exasperation in reading another chaplain’s previous note. Hilsman advocates using sentences versus phrases to succinctly summarize the patient’s immediate life situation and the chaplain’s impressions of the current state of the person’s human spirit. The first sentence, he says, is vital for grabbing the reader’s attention. Examples are given of chart notes with suggested improvements.
The next chapter covers extracting the relevant in a patient encounter for providing holistic, person-centered care and thereby for writing a chart note that will be useful to the other members of the interdisciplinary team. Also, Hilsman discusses issues of confidentiality, ethics, and laws. He concludes with a discussion of outcomes and an epilogue for becoming and remaining a spiritual clinician.
Spiritual Care in Common Terms should be in every chaplain’s library. It is an invaluable tool for preparing and maintaining board certification because it addresses a number of competencies.
Marilyn Williams, BCC, is Director of Spiritual Care at St. Mary’s Health Care System in Athens, GA.