© BRIDGEPOINT 2006 1 Charting as a Spiritual Practice: The art & science of charting CASC...

© BRIDGEPOINT 2006 1

Chartingas a Spiritual Practice:

The art & science of charting

CASC convention, Toronto, Ontario April 2011

Jan Kraus, Spiritual Care Department


• Focus• A habit that brings you back to the Divine

and opens you up to the ways in which the Divine is present

• Theological reflection• A way of connecting the internal with the

external• A way of receiving grace

Spiritual Practice


Why Bother?

• Fully participating members of the health care team must chart

• “If it is not written down – it did not happen”

• It is hospital policy

• It is line with CASC’ s standard of Professional Practice


• To serve the patient

• To serve the team

Benefits


To Serve the Patient:

• To record our assessment and intervention

• To build an appropriate plan

• To provide continuity


• To protect the patient from unwanted service/rituals

• To provide accountability to the patient

• To provide opportunity for education/growth

To Serve the Patient:


To Serve the Team:

• To advocate

• To educate

• To share insight

• To humanize the hospitalization

• To engage in research

• To identify funding needs


What are the Benefits to Your Practice?

• Promotes a holistic approach in the treatment setting

• Creates room to claim what you do and your specialty

• Supports communication with the multi-disciplinary team

• Helps you set priorities

Benefits to your practice


But …..how do I do it ???????



Pause, take a deep breath

One step at a time

http://www.google.ca/imgres?imgurl=http://www.the-peace-project.org/images/labyrinth_chartres_orig_600pix.gif&imgrefurl=http://www.the-peace-project.org/fingerlabprint.html&h=588&w=600&sz=29&tbnid=PmDwXyHWBLjqUM:&tbnh=132&tbnw=135&prev=/search?q=images+labyrinth&tbm=isch&tbo=u&zoom=1&q=images+labyrinth&usg=__UWC7yh25H4W-6ZTESgtNCVazIxs=&sa=X&ei=UF2jTfuUEcP00gH1r8yQBQ&ved=0CB8Q9QEwAQ


Grab your Guidelines

Remember

Your CPE tools

Pruyser, Fitchett & friends



Story Telling

• Our chart notes help tell the patient’s story

Professional Story Teller


Questions to ask yourself before charting

• What is the most crucial information you want the team to know?

• What is clinically relevant?

• How will this information serve the patient and the team?

Action, reflection, new action


• What did you observe? What did the patient tell you?

• What was your intervention?

• How did the patient (family member) respond to your intervention?

More questions


Questions to ask yourself before charting

• What is your analysis of the spiritual issues the patient is addressing?

• What issues would you like to address during your future visits?

• What referrals do you need to make?

• What information is essential to protect the patients or the team?

More questions


Charting Essentials

• Data - objective and subjective

• Analysis - spiritual issue patient is addressing

• Action – what did you do?

• Response –the patient’s words or actions

• Plan – what next?


Action, reflection, new action

Spiritual

Analysis


Data• Why are you seeing this patient – who

referred you? – Patient request; – Family request– Team meeting; – Case finding; – Healthcare professional; MD, OT, PT, RN, RPN,

RT, SLP, SW– Community clergy;

Data


Data

• Did you review the chart? • How did you obtain consent?• What did you observe?

» How does the patient look to you – downcast, happy, worried, crying etc.

• What did the patient tell you?

Data


Analysis

• What is the spiritual issue this patient is facing? This may or may not have been directly stated in the visit.

• Pt is facing spiritual issue of ….• Pt is exploring spiritual issue of …

Analysis


Some examples:• Complicated grief, and/or multiple losses • Crisis of faith• Spiritual growth & development• Crisis of meaning & purpose• Values clarification• Grace & forgiveness• Desire to reconnect with faith community

Analysis


Analysis

• In what ways do you see the spiritual issue impacting the patient’s physical and emotional health?


Action

• Use ACTION VERBS to describe your intervention What did you do?

Action


ACTION VERBS• Addressed• Affirmed• Arranged• Assessed• Created• Communicated• Educated• Encouraged• Engaged• Explored

• Facilitated• Invited • Informed• Offered• Prayed• Provided• Promoted• Read• Supported• Searched

Action Verbs


Examples of phrases that reflect our action

• Addressed the issue of loss/grief/ healthy or maladaptive coping …….

• Affirmed pt’s experience of ………

• Assessed pt spiritual need at the present time

Examples of phrases that reflect our practice



• Created a safe environment for the pt to express their concerns

• Communicated pt’s concerns to NP/MD/RD/RT/RN etc…



• Educated about .. spiritual care services

commonalities of human response to loss, crisis or illness (normalizing)

• Encouraged verbalize of experience of hospitalization and illness

More Examples



• Engaged in active listening; in building a therapeutic relationship in cognitive re-structuringin life review

• Explored pt’s belief system and how it impacts their healing process



• Facilitated contact with;a local faith community/leader family meetingcommunication between the family

members• Informed about spiritual care services

available to the pt/ how to contact a chaplain

More Examples


• Invited pt to express their feelings of …

• Prayed with the pt/family per pt. request for …

forgiveness, healing, acceptance, etc…

More Examples



• Provided …. … spiritual support and guidance… continuity of care/community… safe environment

• Promoted the continuation of religious/spiritual practice while in the hospital



• Read Sacred Scriptures as per pt. request

• Supported pt’s expression of feelings of …religious and spiritual beliefs practices religious doubt

More Examples



• Searched for meaning and purpose that the pt assigns to their life experience and current suffering

• Unable to complete assessment at this time due to (be specific)



Response

• How did the patient respond to your action/intervention?

»Actively engaged »Disclosed information about self and

experience – what is it?»Requested …»Expressed gratitude for …

Response


Plan

• What will you do next?– Discharged from active case load– Will follow up (when and for what purpose)– Will consult with …– Will facilitate …– Will address the issue of …– Will reassess or complete assessment (Ax = assessment)– Will inform …– Will refer to …– Will arrange for … porter service for transportation to services– Will arrange for communion/clergy follow up/SOS/anointing

Plan


Always!!!!!!!

Use pastoral prudence in what you write.

Ask yourself, “Will this information serve and protect the patient?”

Beware the legal complications of shadow charts

Always!


Variations

• Charting is like walking a labyrinth

Spiritual practice


http://en.wikipedia.org/wiki/File:Labyrinth_1_(from_Nordisk_familjebok).svg

http://en.wikipedia.org/wiki/File:Chakravyuha-labyrinth.svg


Focus note

• Focus: Spiritual/Cultural• Data:• Analysis: • Action: • Response: • Plan:• Your signature and title

Focus Note


Contact

• Jan K. Kraus, M. Div– Manager, Spiritual Care Department Bridgepoint Health – CASC Specialist in Institutional Ministry– CASC Teaching Supervisor

– 416-461-8252 x 2172

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