Dr. Brent Peery on a standard of care

Documenting Our Care: Chaplaincy Charting

“Chaplain, you need to go in there and do that thing you do. They need help.”

Many of us have had similar referrals from hospital staff or physicians. It implies both value of and mystification about our work. There are definitely inexplicable aspects of our work that cannot be quantified. However, I have come to believe in the value of articulating the demonstrable parts of our care. It helps us offer better care. It also helps the rest of our partners on the interdisciplinary healthcare team understand our professional contributions and make appropriate referrals.

To that end, Memorial Hermann Healthcare System (MHHS) chaplains have emphasized outcome-oriented chaplaincy [1] in the last few years. As a part of that protocol emphasis we have developed a standard of care for chaplaincy charting. It is a five-part model for documenting our care.

First, we state the reason for our encounter with the patient or family member: Why is the chaplain making the visit? Is it because of a referral? Is it from making rounds? Is it a response to a request for literature or ritual? Is it a follow up visit?

Second, we explain the interventions we offer: What does the chaplain do to help the person? This might include empathic listening, encouragement, prayer, grief support, ritual, or ethics consultation.

Third, we comment on the outcome of the encounter: What difference did the chaplain’s interventions make? Descriptive phrases we might use include: appeared to be relaxed as visit progressed; stated felt less frightened; expressed grief and sadness with tears; stated he/she appreciated support; or, stated that he/she felt better.

Fourth, we make a brief assessment statement: How would the chaplain summarize this person’s current emotional/spiritual/relational state to the rest of the interdisciplinary healthcare team? For example, we might say: “patient concerned about dying during procedure;” “family seems to be coping well at present;” “patient remembering death of spouse at third anniversary;” “patient worried about who is providing care for parents;” “patient reports strong support from family and faith community;” “patient described feeling of guilt about lapse of religious practices;” “spouse expressed confusion about prognosis.”

Fifth, we record our plan for continued care of this person: What does the chaplain intend to do further or recommend to the interdisciplinary healthcare team? Examples include: no follow up at this time; will follow PRN; will continue with supportive care next week; suggest social work consult; etc.

In summary, the MHHS model of chaplaincy charting is: Reason, Interventions, Outcomes, Assessment, Plan. Some chaplains have found the mnemonic phrase “Run In On A Prayer” helpful in remembering the model.

After a couple of years of using this model, it has been helpful in several ways. For example, it helps us be more intentional about the care we give. Often I have found myself, while charting a visit, being forced by this model to evaluate the quality of my work. How did the visit go? What were the needs? Are there ways I could have been more helpful? It is helping me to become a better chaplain? Additionally, this charting model is helping us communicate more clearly with the rest of the healthcare team. As they better understand what we do, they appreciate and utilize our services more effectively.

Footnote:

[1] VandeCreek, Larry and Arthur M. Lucas, eds. The Discipline for Pastoral Care Giving: Foundations for Outcome Oriented Chaplaincy. New York: Haworth Press, 2001.

Do you have thoughts about professional practice you’d like to share with your colleagues? Send an e-mail info@PlainViews.org.