By Carolanne Hauck
More than ever, chaplains need to convey their contribution to patient outcomes and experience. Professional documentation of the chaplain assessment is a good place to start, and we are fortunate that, as a profession, formulating and utilizing spiritual assessments are competencies required for certification:
PAS6: Formulate and utilize spiritual assessments in order to contribute to plans of care.
One very positive change that came about through the implementation of the electronic medical record for us at LGHealth/Penn Medicine was finding a way to capitalize on the change in the way we document our work. Chaplain documentation on the EMR has proved to be an excellent tool for chaplains to increase the level of professionalism of their notes, with the added benefit of recognition of healthcare professionals and appreciation for chaplains’ work.
Before EMR, handwritten notes on the patient chart were not easily accessible, and we often wondered if our notes were even read by other staff. To be honest, we did not focus much of our attention on our notes before the plan to implement electronic documentation in our chosen EMR, Epic. Planning for Epic made us assess our work and, more importantly, challenged us to find a better way to convey our contributions to patient well-being.
A well-written spiritual assessment provides insight into the values, spiritual risks, struggles, and resources that a patient brings to the current hospitalization. An understanding of what is meaningful to the patient provides all staff with the opportunity to care for the patient holistically.
There are many very good options for how to write a spiritual assessment. As we searched for what would work best for us, and through trial and error, we devised our own template. Assessment is just one part of our documentation. The addition of patient Goals, chaplain Interventions, Outcomes, and eventually Plan, was the best way to sufficiently convey the chaplain contribution to patient care.
Below is a copy of the template used for each patient visit, with a brief explanation for the chaplain’s reference of what to include, as well as an example of a completed note. The descriptions are very helpful when staff members feel stuck and when teaching interns and residents how to document on the plan of care. Of course, the template that is used on the chart does not include the descriptors.
Once we became familiar with using the template, we looked for ways to add metrics to our work for the purposes of quality improvement. For example, it became important to evaluate the quality of assessments. The writing guide for assessments provided the means for self-evaluation as well as evaluation by the director of the department. Below are examples of two metrics that we have used.
Goal II: 80% of documented outcomes directly linked to goals.
This process has helped chaplains evaluate their own notes more fully and has greatly improved the professionalism of their spiritual assessments. But initially, the metrics were well below desirable levels. Percentages were 70% for Goal I and 45% for Goal II. At the start, we found that chaplains struggled to adequately link outcomes and goals. Asking ourselves about the barriers fostered great conversations about the work and eventually helped us formulate an education plan that quickly improved our efforts. Since then, charts are randomly reviewed once a week and the metrics are posted and shared with the department. As of late, percentages for both goals have met and exceeded the desired outcome!
Over time, we have also added a chaplain documentation template for follow-up care, and one for family care. Staff chaplains have also devised a “Smart Phrase” tool that gives the chaplain easy access to a list of interventions and potential goals. This tool comes in handy when the chaplain is very busy or might need a bit of help with his or her writing.
Most notable, however, is the evidence that others are using our notes. Chaplains see references to their assessments in the notes of social workers, case managers, RNs, and the palliative care team. Recently, a young pregnant patient lost her baby in a car accident. Because of the mother’s extensive physical injuries, she recovered on a unit that does not typically care for patients with loss. Through the chaplain documentation, staff caring for the patient found many helpful ways to give the kind of sensitive care that the patient needed. The chaplain’s documentation conveyed what the patient found meaningful in the midst of her loss as well as tools that the patient was using to cope. Members of the team thanked the pastoral care staff often for the helpfulness of their notes and stated that they felt more prepared to care for the unique needs of the grieving patient.
Providing a good spiritual assessment is one of many tools that chaplains use to contribute to patient and family experience and outcomes. Documenting in a professional manner provides concrete evidence that what we do matters.
Carolanne B. Hauck, BCC, is director of chaplaincy care and education and volunteer services at Penn Medicine Lancaster General Health in Lancaster, PA.