Charting Our Course: Chaplain Documentation as a Performance Improvement Project

Spiritual AIM: assessment and documentation of spiritual needs in patients with cancer

The chaplain is an essential member of the palliative care (PC) team, yet, standard methods to document chaplain assessments are lacking. The study team performed a retrospective analysis of chaplaincy documentation in an outpatient PC clinic at an academic medical center over 6 months (April 2017 to October 2017). The study team identified unique adult patients with cancer, then manually extracted variables from the electronic medical record. The primary objective was to assess the number of spiritual assessments documented by the chaplain. Secondary objectives included descriptive analysis of identified spiritual needs. Out of the 376 total patient encounters, 292 (77.8%) included documentation of a chaplain's spiritual assessment. The most frequent spiritual need was self-worth/community (n = 163, 55.8%).This study demonstrates that chaplains can effectively document Spiritual AIM-based screening and assessment. Moreover, this may be an effective documentation method across institutions to facilitate chaplain-based data.

The development of an outcome oriented and research informed spiritual care assessment and documentation form for the electronic health record in an adult hospital setting

Standards for professional chaplaincy expect chaplains to document their work in patients' medical records, but no agreed upon standard for the content or format of such documentation exists. With the adoption of Electronic Health Records (EHRs) in many hospitals, chaplains may utilize a provided electronic form or one that can be customized from a basic format to departmental specifications. Ideally, the documentation form supports and reflects the work of chaplains in their specific clinical context. Outcome oriented models of chaplaincy and an increasing focus on a research informed practice of spiritual care should determine the format and content of chaplains' documentation in the EHR. This article describes how a chaplaincy department in an adult academic Level I trauma center designed and implemented a spiritual care documentation form for the EHR. The documentation template is informed by clinical expertise and by research about patients' meaning-making activities and patients' experience of connectedness in the context of illness. It integrates a consensus-based assessment form with narrative documentation options, searchable selections, and an outcome-oriented plan of care.

Chart Audit of Spiritual Care Documentation: Continuous Quality Improvement

Eight spiritual care practitioners at an acute care teaching hospital undertook a systematic chart audit of their documentation practices in the patient electronic health record. The purpose was to evaluate their practices using the standards of their professional association and regulatory college. A preliminary "mock audit" was essential for the overall success of the audit. Plans for ongoing chart audits will lead to continuous quality improvement. A limitation was that their manager acted as both improvement coach and performance evaluator.