Charting for St. Mark’s Spiritual Care · Web viewThis document provides guidelines for charting...

JUNE 2014: Rev3Charting for St. Mark’s Spiritual Care

This document provides guidelines for charting spiritual care visits at St. Mark’s hospital. This version was revised for the June 2014 CPE summer intensive.

Your charting will:

Communicate important information to other chaplains who have to follow up Share useful information with the rest of the medical team Document your visit with the patient for medical documentation Provide a summary of pertinent information from your visit that you can refer to later

Nothing replaces a face to face conversation! While charting is an important part of team communication and medical documentation, it is not meant to replace talking face to face with nurses, doctors, chaplains and other staff.

We hope that charting should be

Quick and easy, no more than a couple of minutes per patient Concise and clear, so that other chaplains can read it quickly

This document is divided into two sections: Charting Guidelines that we hope will help you know what kind of information to chart, and Charting in Epic, which we hope will provide you with information about the Epic interface and where to chart what information.

Charting GuidelinesA thorough chaplaincy note should include answers to the following questions. Such a note is often called for when a chaplaincy consult has been requested, after any in-depth visit: initial, follow-up, care conference, trauma, etc., and any other occasion where a detailed note is useful.

In Epic, your narrative notes (under “Notes” below) are available to the entire medical team. Be mindful to include pertinent information and document information that may be useful to nurses, doctors and therapists – for example, if the patient wants the LDS elders or Catholic lay ministers to visit, or if they have fears about their discharge or seem unclear about their illness or treatment.

1. Why did you make this visit? (i.e. the reason for the visit) – note here if anyone referred or suggested this visit and why.

a. Refer to types of visits, types of spiritual assessments2. What did you see, hear, ask about, and talk about (pertinent to the reason for the visit) while

you were there? (i.e. the content of the visit) Remember that you only need to document pertinent information; imagine what another chaplain would want to know if visiting the patient or what might be helpful to medical staff. This can/should include (if pertinent):

a. Patient’s understanding of, relationship to, and attitude about illness/injuriesb. Data about family – names, relationships, etc. – especially if this has not been previously

documented

Spiritual Care Charting: CONFIDENTIAL Page 1


c. Information about the patients/family’s spirituality – e.g. religious affiliation if any, sources of hope, ways of making meaning, valued practices, needs/issues/resources, etc.

d. A comment on the patient’s or family’s demeanor, affect, moode. Information about the patient as a person – job, hobbies, interests, what patient is

“famous” for, etc.f. Resources – both internal and external – that the patient and family can draw upong. What is the patient’s status for advanced directives? Who in the family are decision-

makers? Medical agents? (Important on the ICU)h. Is there anything the patient is wondering about or any worries? This information can

be particularly useful for medical staff reading your notes.3. What do you make of the situation based on the reason for the visit and on what you observed

and heard? (i.e. Your pastoral and/or spiritual assessment)4. What did you do during this visit based on your assessment?* (i.e. your pastoral interventions)5. What changes did you observe – if any – in the patient/family interventions? (better/worse, etc

– can be useful to quote the patient/family, especially if positive “that was very helpful, thanks”)6. What more – if anything - needs to be done in the future given all of the above? (i.e. your plan)

a. Does the patient want another chaplain to visit?b. Is there something about the family you would want another chaplain to know?c. If the patient is Catholic do they want to see the Catholic Eucharistic ministers? Y/Nd. If the patient is LDS do they want to see the visiting LDS elders? Do they want

sacrament? Y/N7. In the event of a death, did you call IDS? Was the mortuary designated? Record the IDS status,

referral number and mortuary information in a note, if possible.

* When documenting assessments, these categories may be useful:

1. Spiritual strengths2. Spiritual concerns3. Spiritual distress4. Spiritual despair

While this is a wide range of possible information, in any specific note, be as concise as possible, do not use medical diagnostic terms such as depressed, confused, infected, etc. Remember not to abbreviate, as your abbreviations may be misunderstood by others, or relay information you had not intended.

Remember to chart when you do the visit (if you chart later, please note the time of the visit). Best not to leave charting until the end of the day – especially when on-call – you may get interrupted, forget details, or even forget to chart at all.

Useful Language / ConceptsThe following section provides some useful language and concepts that may help guide charting information. In Epic, some of this information is built into the Doc Flowsheets section of the interface.



Explored/Discussed Types of pastoral visits (listed in Doc Flowsheets, see Epic section below) Spiritual journey, spiritual direction Struggles with hospitalization Seemed unclear about condition / treatment Faith crisis Bereavement Theodicy / Concept of Evil/Punishment Gratitude / Appreciation Beliefs / Theology / Doctrine Forgiveness Impact of illness on life Vocation / Career Plans / Life Purpose Losses due to illness Compound Grief Family Relationships / Family Dynamics

Objectives for On-Going Visits: Pastoral Support / Pastoral Listening, Hospitality, Assessment, Pastoral Support with Advanced Directives

Barriers to Visit: Patient Asleep, Patient Intubated, Patient Not Verbal, Struggled to Understand Each Other, Unable to Speak Clearly, Patient Wants to Wait for Family.

Recommendations: Refer to Catholic Priest, LDS Elders, Nurse, Social Work, Case Management, etc., Lutheran Pastor Meeting Spiritual Needs, Patient Has Faith Community for Spiritual Support, Welcomes Pastoral Support, Continued Pastoral/Spiritual Visits, Welcomes Spiritual Care, Appreciates Prayer/Ritual

Types of Pastoral/Spiritual Visits: Addiction, Admission to Hospital, Advance Directives, Alienation from Divine/Family/Society, Anamnesis, Anger, Anxiety Reduction, Attending at Time of Death, Bereavement, Communion, Concept of Death, Conflict Resolution, Consultations, Critical Care, Despair/Hopelessness, DNR Consultation, Dying, Ethics, Exegesis of Personal Narrative, Family Systems Issues, Fears/Worries, Forgiveness, Fifth Step (Admit Wrongs/Amends), Financial Concerns/Worry, Grief, Initial Spiritual Assessment, Isolation, Issues in Cancer, Medical Treatment Plan, Narrative Exploration, Post-Operative Visit, Prayer Request, Pre-Operative Visit, Presence for Codes, Purpose/Meaning-Making/Self-Image, Referral, Reflection, Relationship with God, Sacrament of the Sick, Sacraments/Rites/Rituals, Scripture, Social Skills Concerns, Spiritual Community, Spiritual Growth, Spiritual Journey, Staff Spiritual Direction, Struggles with Being a Patient, Suicide, Theodicy (Concept of Punishment/Evil)

Spiritual Assessment (Fitchett): Beliefs and Meaning, Vocation and Consequences, Experience and Emotion, Courage and Growth, Ritual and Practice, Community, Authority and Guidance.

Grace-Bearing (Fr. Ure): Prophet (Advocate for Right), Teaching (Meaning of Events/Information), Listening (In-Depth Listening/Non-Anxious Presence), Ritualize (Prayer, Sacraments, Appropriate Touch),



Hospitality (Brief Social Visit, Clean and Fetch), Referral (Access to Grace, LDS Elders, Priest, Rabbi, Medical, Case Management, Social Work), Solitude (Leave Them Alone, Respect Privacy)

Theological Issues (Pruyser): Awareness of the Holy, Providence, Faith, Grace/Gratefulness, Repentance, Communion, Sense of Vocation/Calling

Ten Common Spiritual Concerns: Anger Towards God, Anticipatory Grief, Afterlife, Beliefs/Conflicts, Dying/Transition, Medical Plan, Moral/Ethical Questions, Shame, Suffering, Unresolved Guilt

Pertinent Information / BoundariesOne of the things you can do in charting that is useful to other chaplains is to think about what you would want to know if you were following up with the patient. Does this patient want further spiritual care visits? (Particularly useful when a nurse makes a referral for a patient who already said “no” to a chaplain)

Examples that could be more pertinent:

1. PT is a nun; sisters ministering to patienta. What type of nun? Buddhist? Catholic? Do they want the Catholic visitors?b. Would the patient like a visit from other spiritual care?c. “PT is a Catholic nun, sisters ministering to her, No Catholic visitors”

2. PT would like Greek Orthodox Priest to visit if in the buildinga. Did the chaplain call a Greek Orthodox Priest? Should another chaplain call?b. “PT would like Greek Orthodox Priest if in the building, did not call”

3. PT is Catholic, Shared spiritual awakeninga. Does this patient want to be on the Catholic visitors list?b. “PT is Catholic, Shared spiritual awakening, did not ask about visitors”

4. PT is much improved but confused me with her doctora. Would this patient like any other spiritual care? b. “PT much improved, confused me with her doctor, wants frequent spiritual care visits”

5. PT has good support from his ward and familya. Does this patient want the LDS elders to visit? Do they want sacrament? b. “PT has good support from ward and family, would like sacrament on Sundays”

It can be particularly helpful to note if the patient wants future spiritual care visits.

Remember that everything you chart is a matter of record – a patient can request it through medical records, the courts can request it – your work is available, chart with consideration, respect and dignity, include what you hope will be the most useful information written with loving kindness.



Charting in EpicWe chart in Epic – there is a red icon on most desktops that says “Epic” – when you click it you will see a login screen.

Figure 1: Epic Login Screen

Enter your 3-4 ID into the “User” field and your password into the “Password” field. You will pause at a department selection screen. Select “SUT HCAPS SMH HEART CTR [10000003001]” (usually it will be the default selection) and click the “Ok” button.

There are two main interface areas in Epic; the Census and the Patient Lists.

Census is used by registration and volunteers; You need to chart information for visiting LDS and Catholic Clergy in the census so that they can access it.

Patient Lists is used by medical staff and the healthcare team; You need to chart in TWO places for other chaplains and the medical team in the Patient Lists.

The CensusWhen you first log in, the first screen that comes up is the Census – it is used by volunteers and registration so has the most high-level information – patient name, unit, bed, whether they are private or not (is their name hidden), their service (healthcare unit), religion, clergy visit preference.



Figure 2: Epic Census List

To set a patient’s preference for clergy visit, the Census List must have the correct Religion and Clergy Visit options.

To be on the LDS Elders list, Religion must say “Latter Day Saint Mormon” and Clergy Visit must say “Yes”

To be on the list for the Catholic visitors list, Religion must say “Catholic” and Clergy Visit must say “Yes”

Catholic Visitors: At St. Mark’s we have Catholic visitors from St. Vincent’s parish who bring the Eucharist and offer prayers week days at about 10am. Their list is printed by the volunteers when they arrive; you should try to assess your Catholic patients, and update their Clergy Visit field so they will appear on the visitors list by that time of the morning.

LDS Elders: We have LDS elders who come some week-day evenings and Sundays to bring around Sacrament. They offer a blessing, check-in with our LDS patients. Their list is pulled and printed after 5PM and on Sunday, you should try to assess your LDS patients to see if they want them to visit by that time of day or before the weekend.

UPDATING THE CENSUSThere are three tasks you may need to do in the Census List.

1. Update the Clergy Visit FieldTo change the Clergy Visit field, find the patient in the list (it can be sorted by any of the column titles, click one to change the sort) and click on the Clergy Visit field. Change it to “Y” or “N” accordingly.

Figure 3: Updating Clergy Visit


Click the magnifying glass icon in Clergy Visit and select “Yes” or “No”


2. Updating the Patient’s ReligionSelect the patient. Click on the Update button in the upper right. This will open the patient registration information screen. You can change the religion by clicking the magnifying glass in the religion field to get a drop down.

3. Adding a Comment for the VolunteersYou may want to add a comment for the LDS or Catholic volunteers – such as “5/27 Requested a blessing” or “Sunday Sacrament Only PLS” or “Asked for prayer”. If you want to add a brief (a few words) comment that will show up on the volunteer printout, you can add it in the Comment box of the patient registration screen.

Figure 4: Patient Registration Info - Spiritual Care Interface

When you fill in the Census, please enter “N” for anyone who is not interested in a Clergy Visit, and “Y” for anyone who does want a visit from outside clergy, even if their faith is not LDS or Catholic.


Update Religion Here by clicking the magnifying glass icon to get a list and picking the new religion.

Click “Finish” when done

You can add a note for the volunteers here such as “Wants Sun Sacrament” or “Wants blessing” – look at the LDS or Catholic list for examples. It may be helpful to date your note.


Patient ListsTo get to the patient lists, you need to use the icons above the Census area in Epic. There are four icons, the first one, the cross, moon and star is for the Pastoral Care census. The third one, the one that looks like a list with a person is for the Patient Lists. The Patient List has a “MyList” area for a summary list of patients and the “Patient Chart” which is specific to a single patient.

Figure 5: Selecting the Patient List Interface

Figure 6: The MyList Interface


This is the “My List” area where you create and manage your own lists

These are the comprehensive Available Lists of all units in the hospital

These icons allow you to move between patient lists and census lists


Figure 7: Creating your own MyList

Epic does not have any patient lists set up by default – you will need to create one of the patients you want to see.

Figure 8: Selecting Fields for your MyList


To create a new list for yourself, click “CREATE”

“My Lists” is where you will organize and manage your own lists of patients. You can set them up to display the information you want, in the order you want, and then drag a unit of patients from the “Available Lists” to populate them.

There are several department-wide lists in available lists we will set up. First, let’s create a new list.

Click the Create button

Choose the fields from here. You want at least:

Room/BedPatient NameAge/SexReligionClergy VisitSC RecommendationSC NotesCode Status

Click “Add” to move the selected field to your new list.

When you are done selecting your fields, click “Accept” at the bottom of the dialog to create your new list – now you have to populate your list with patients.


Once you have chosen the fields you want for your mylist, named it, and clicked “Accept” your list should appear on the left-hand side. Initially it won’t have any patients on it – you need to select the patients you want to add. Note that “SC Recommendation” and “SC Notes” match to the Doc Flowsheets in the patient chart – more detail on that in the patient chart section.

Figure 9: Patients Visible on the MyList

You will need at least two MyLists – the first one for your unit, the second one for Consults. Spiritual Care Consults are doctor and nursing requests for a chaplain to see a patient. Create one MyList for your unit, and one for consults.

We also use a “Requests” list where we can drag patients we want another chaplain to see – that list is shared by the department administrator and will appear in your Epic interface auto-magically. You can put a patient on the “Requests” list by dragging them to it. Once they are discharged you remove them by right-clicking and selecting “Remove”

When you are on-call or covering the hospital, you are responsible for checking the Consults and the Requests lists please make sure you can do it.


Click on “System List (SMH)” and then “Units” to open the list of departments and drag one up to your My List – pick the one for your unit and drag it up to your mylist.

Note you can print a patient My List using the print button


Charting on a Specific PatientTo open a chart, you can double click the patient name or select the patient and click “Open Chart”

Figure 10: Opening a Patient Chart

Figure 11: The Patient Chart


There are two “Sticky Notes” where you can put temporary information such as a note to the physician saying “This patient wants to be DNR, please check with them and write an order.” Or a note to the nurse saying “Took patient an extra blanket”

There are two places you should chart on a patient.

1. Doc Flowsheets – Summary information for other chaplains. Only visible to spiritual care.

2. Notes – Narrative note with details. Visible to the whole care team.

Select a patient in the MyList row.Click “Open Chart”

Information about the SC Note encounter with the patient is available here – be sure to check the dates, notes display after a patient is discharged and readmitted.


The Doc Flowsheets area is specific to Spiritual Care. This is where you chart information that is used by other Chaplains. (Remember that everything you chart is available through medical records; this is a patient accessible record) Doc Flowsheets has multiple choice fields to help define visits. You should chart once for each “Encounter” with a patient.

Figure 12: Doc Flowsheets Encounter List

An “Encounter” has several different fields and options for spiritual care:

Visited With: The person you saw Visit Type: The type of visit – Spiritual Assessment, Advanced Directives, etc Visit Request From: Mostly rounds, medical staff, another chaplain – who asked for the visit Spiritual Leader Visit? Not really necessary, its left over from our first incarnation. Ignore if you

want. Spiritual Action Taken: What did you do with the patient? Rituals Done: Not really necessary, left over. Ignore this if you want. SC Recommendation: What do you recommend SC do for the person, pick ALL that apply. SC Notes: What information do you want another chaplain to know.

o SC Notes Conventions: CATH Y/N or LDS Y/N – Put this in when a SC person assesses Catholic or LDS

patients SC PLS Visit – If you hope another Chaplain can visit the patient. Wants SC – If the patient wants more Spiritual Care SC Welcome – If the patient welcomes Spiritual Care, but isn’t motivated for

moreo Please use these conventions in your SC Notes – they help us to understand each other.

Yes, there is some redundancy with SC Recommendation and Clergy Visit, but the time expense is minimal and these practices really help us to recognize what another Chaplain did with a patient.


Chart specific encounters here in Doc Flowsheets


Plan of Care NotesPlan of Care Note are the third charting area you are required to fulfill. They are visible to the entire care team, other chaplains and medical personnel. They are narrative and free-form.

Figure 13: Opening Notes

Figure 14: Creating a New Note


Click the “Notes” tab to open Plan of Care notes.

Once you have the Notes list open, you can add a note with “New Note”

Your plan of care notes are an important part of charting – they are the only notes that other disciplines can see.

Please write a Plan of Care note every time you visit a patient – you can just quickly say “Provided pastoral listening. Continue SC” if the visit was routine, but if there are issues you think would be helpful to the care team, or details that might be useful, include them.

Such as; family member names and contact information, things the patient might want the nurse or care team to know or ask about, such as if the patient is under significant stress that may affect their satisfaction or health.

You can also note different service you provide in spiritual care, the status of advanced directives and more.

I suggest you look at a few patients who have Doc Flowsheets and SC Notes to see if they have a Plan of Care note and what the other chaplain wrote.


Figure 15: Selecting Note Type

Figure 16: Signing your Note

Once you have updated the Census (if necessary), filled in a Doc Flowsheet encounter, and entered a Plan of Care note, you have effectively charted a visit with a patient.


Hit the magnifying glass drop-down icon and select “Plan of Care” from the Category Select List

When you are done with your Plan of Care note, click the Sign button to insert it into the list.


If you were responding to a consult request from a nurse or doctor, and believe that Spiritual Care is done with the patient for now (we have fulfilled the purpose for the consult request) then you make want to mark the consult “Complete” – but only if we have fulfilled the request.

OTHER STUFFEpic is an extensive and rich charting system – and there is a lot of information available to you in it. Look through the Plan of Care notes to see notes left by nursing, doctors and other disciplines. Look at the patient Facesheet (a link on the chart home page) to see family and contact information. The overview has a lot of healthcare information you will need when calling donor services.

On the top-bar you have an OR schedule that can be used to print out a custom Spiritual Care pre-operative schedule for your pre-op day.

For more information on charting, or for help with charting, ask one of the staff chaplains, a supervisor, a resident preferably BEFORE you are on-call and on your own.


If spiritual care has fulfilled the consult request, click “COMPLETE” – leave it open if we have not yet fulfilled the request, such as leaving behind advanced directive paperwork, but needing to come back to complete it.

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Charting for St. Mark’s Spiritual Care · Web viewThis document provides guidelines for charting...

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