This is a continuation of my reflections on the Standards of Practice for Professional Chaplains in Acute Care. If you are interested, you can access Standards and related information from this page. You can find my earlier posts on this subject by clicking on the link for Standards of Practice under the Label menu in the sidebar.
The next section of “Section 1: Chaplaincy Care With Patients And Families” is “Standard 3: Documentation of Care.” The specific standard is “The chaplain enters information into the patient’s medical record that is relevant to the patient’s medical, psycho-social, and spiritual/religious goals of care.” This follows clearly from the Standards on Assessment and Delivery of Care. Information from the assessment directs provision of care; and having been provided, it is important that the care be documented. It is axiomatic in health care that “if it didn’t get documented, it didn’t get done” – that is, no one coming along later, whether another member of the team or a coder in Patient Accounts, will know what has been done for and with a patient, and what ought to be done next. If anything, this is more incumbent on spiritual care providers than on others. If a nurse gives a medication, there are very likely going to be measures affected – lab values, blood pressure, etc. As I have noted, our outcomes are rarely so readily connected directly to our work; and that makes it all the more important that our work be documented.
I have already considered that phrase, “relevant to the patient’s medical, psycho-social, and spiritual/religious goals of care” in a previous post, or at least about what is “relevant.” It should be noted, though, that central to this Standard, as understood by the Committee, is some further elaboration on “information… relevant to the patient’s medical, psycho-social, and spiritual/religious goals of care.” The Interpretation section includes this:
Documentation should include but is not limited to the following:
• Spiritual/religious preference and desire for or refusal of on-going chaplaincy care.
• Reason for encounter. • Critical elements of spiritual/religious assessment.
• Patient’s desired outcome with regard to care plan.
• Chaplain’s plan of care relevant to patient/family goals.
• Indication of referrals made by chaplain on behalf of patient/family.
• Relevant outcomes resulting from chaplain’s intervention.
This list of categories that we might call “necessary, if not necessarily sufficient,” provides its own framework of what is relevant. The question remains, though, as to whether these are the most appropriate categories.
Even accepting this list of “necessary if not sufficient” categories, there is another issue: what about our tools for documentation? Are they adequate to the task? Do we have adequate access? Are we using our tools as well as we can; and what might that mean? I will address that in a subsequent post.