Charting Spiritual Care : The Emerging Role of Chaplaincy Records in Global Health Care /: The Emerging Role of Chaplaincy Records in Global Health Care. (2020)

• Record Type: Book
• Further Information: Note: Simon Peng-Keller, David Neuhold.
• Editors: Peng-Keller, Simon; Neuhold, David
• Contents: Simon Peng-Keller/David Neuhold Recording spiritual care in electronic medical records. Overview on an ongoing developmentAbstract: The introductory contribution begins with a historically oriented sketch. By referring to ancient and early modern practices, the relationship between spiritual (self-)care and various forms of documentation is broadened. The focus is then on the documentation efforts of clinical pastoral care in the 20th century. The recording of clinical pastoral care is by no means new. The efforts of thephysician Richard Cabot and the theologian Russel L. Dicks in the 1930s show this impressively. In afurther step, more recent developments, which were important in the run-up to the electronic medical record (EMR) that produced it, are pursued. An exemplary view, namely of Kenya, expands what is depicted into another context beyond the western realm. Finally, the chapter gives an overview of the state of research and literature on the topic and some of the questions discussed therein, such as the pastoral mystery and the crucial matter of confidentiality. Possible unintended consequences of the emerging practice also are considered. Thus, the discussion is complex, multifaceted, and changing. Keywords: Documentation, history, (self-)care, EMR, pastoral mystery, confidentiality, unintended side effects. I. Basic considerations Eckhard Frick Psychiatric-psychotherapeutic perspectiveAbstract: Proactively addressing spiritual and religious (s/r) issues has a strong intervention effect on patients that is generally more important than the detailed content of spiritual screenings and assessments. When asked about s/r needs or problems, patients may feel bothered, surprised, annoyed, or, conversely, satisfied, supported, acknowledged in their coping efforts. Consequently, documentation should first of all reflect whether and how the patient reacts towards the clinician's s/r intervention and whether and how he wants this interaction to be shared in the healthcare team. There is growing evidence that patients want that the carers to take into account the spiritual dimension of health care. Health professionals must, however, respect individual and general boundaries (non-compulsive, non-proselytizing, non-neglecting approach). In psychiatry and psychotherapy, patients' spirituality is less pathologized than in former times and more and more accepted as a universal dimension to human experience, transcending individual religions. In mental health and in other medical fields, s/r may be part of the problem or part of the solution (K. Pargament) or both. Consequently, spiritual charting should not only differentiate pathological / negative and resilient / positive coping but also comprise the patient's s/r health-care preferences and goals as well as the role he or she attributes to the health professional. All in all, a hermeneutical (understanding) approach is required both when communicating with the patient and when putting it into writing for the healthcare team, i.e., «translating» the patient's spirituality and sharing it with different team members respecting their own s/r and professional belongings as well as their experiences and competencies in this field. Key words: Spirituality, psychotherapy, team, patient Guy Jobin Ethical perspectiveAbstract: The introduction of EHRs into clinical practice appears to be irreversible. Where EHRs are used, chaplains have cooperated willingly with this way of reporting and sharing information with other members of the care team. They must, as a result, adapt their own note-taking practices to ensure effective, relevant, and meaningful communication as part of the joint decision-making process. Although EHRs raise ethical issues that can be described as «classic», particularly in connection with confidentiality and access, other questions, just as crucial, have received less attention in the specialized literature and are addressed here. They include recognition for all players in the care relationship (both patients and caregivers) as subjects, and the communication of «non-generic» information such as emotions, values, life history, etc. Key words: Clinical Judgment, Confidentiality, Deontology, Ethics, Recognition Paul Galchutt/Judy Connolly What We Don't Know Can Hurt Us. Spiritual Assessment Notes in Palliative CareAbstract: The research question, «What is helpful as well as missing from palliative chaplain spiritual assessment progress notes, » arose from the context of seeking to know how palliative chaplain spiritual assessment progress notes can best be relevant and make a difference for a patient's care. The information-rich audience to address this question were the non-chaplain palliative care team members. Seven focus groups, two of which were in a children's hospital context, were hosted with forty-two non-chaplain palliative team participants. Through a constant comparative qualitative analysis process, the major results revealed four important considerations for palliative care chaplains. First, palliative interprofessional team members want more help and information regarding a patient's decision making, especially related to a patient's religion and/or spirituality. Second, and in line with palliative care principles, the participants discussed their desire for relevant notation on a patient's sense of suffering and coping. Third, a request was made for the chaplain to consistently document his/her perception of emotion emerging from the patient and/or family. The last major result to emerge was that the progress notes should have a summary content section at the top of the note with the most important information contained there. Palliative care chaplains need to continue to hone progress-note content such that it continues to be relevant and effective in helping make a difference to reduce suffering and improve quality of life with patients and families. Key Words: Palliative Care, assessment progress notes, interprofessional team, quality of life II. National developments and trends Brent PeeryChaplaincy Documentation in a Large U.S. Health SystemCommentary: Simon Peng-Keller Abstract: Chaplaincy documentation practices in the United States have evolved over time. Variation in practice still remains. However, the trend in the profession is toward the expectation that chaplains will document their care. There is also increased expectation regarding the content of that documentation. This chapter contains some of the history and current practice of chaplaincy documentation within the Memorial Hermann Health System in Houston, Texas. It includes a discussion of the who, what, where, when, how, and why of chaplaincy documentation. Memorial Hermann chaplains strive to document care in a manner that bears witness to the holistic humanity of the care recipients. The author also describes the care in a way that helps others understand the important ways professional chaplains contribute to the wellbeing of others. Key Words: Chaplaincy, spiritual care, charting, documentation, electronic medical record Bruno Bélanger/Line Beauregard/Mario Bélanger/Chantal Bergeron Documenting Spiritual Care in CanadaCommentary: Ralph KunzAbstract: Over the past decade or so, the quality of the evaluation note written by a spiritual care provider (ISS) has been a major issue in accountability and the quality of interdisciplinary collaboration. This chapter proposes two models of notes: «the note following a meeting with a user», generally used in acute care, and «the note following a meeting with a relative», generally used in long-term care, in cases where a patient can no longer express himself. These two charting models were developed on the basis of the RESS (Benchmarks for Spiritual Care Assessment) assessment tool, recently developed at the CSsanté, whose usefulness and applicability were assessed in a research study. The note models presented in this chapter are essentially inspired by the vision of spirituality underlying the work of accompanying patients and the development of the RESS. The authors found that the clinical benefits of streamlining an evaluation and note-writing model are a major step forward in a profession that has been rapidly evolving in Quebec in recent years. Keywords: Quebec, spiritual care, quality of interdisciplinary collaboration, spirituality, benefits Christine Hennequin Documenting Spiritual Care in AustraliaCommentary: Livia Wey-MeierAbstract: Documentation in medical records is an important aspect of providing care in Australian health services. Documenting spiritual care in health services has evolved over many decades. A brief historical overview of the models of chaplaincy in Victoria, Australia from the 1950s shows the development from faith-based models to more professional models in the last two decades. Models may include spiritual care faith representatives and volunteers; access to medical records differs for each of these providers. Data collection and describing pastoral interventions in the 1990s as part of an Allied Health project at Austin Health, Heidelberg Victoria was a key milestone as was the inclusion of pastoral care intervention codes in the Australian ICD-10_AM/ACHI/ACS codes in 2002. As a peak body, the Healthcare Chaplaincy Council of Victoria and later Spiritual Health Victoria continued to develop documentation guidelines including consistent ways of collecting data and describing interventions. Reporting on spiritual care activity to the Victorian government's Department of Health and Human Services emphasised this requirement to develop a minimum dataset and to educate the spiritual care sector. A Spiritual Care Minimum Data Set Framework was developed in 2015 and evaluated. Revised guidelines were disseminated by Spiritual Health Victoria in 2019. Three case studies of Victorian hospitals illustrate how documenting in electronic and paper medical records currently meet the Spiritu
• Publisher Details: Cham : Springer
• Publication Date: 2020
• Copyright Date: 2020
• Extent: 1 online resource (232 pages)
• Subjects: Medicine; Medical care; Public health; Psychology and religion; Medical ethics; Religion -- General; Religion -- Psychology of Religion; Medical -- Ethics; Religious issues & debates; Psychology; Bio-ethics; Medical -- General; Health systems & services; Health--Religious aspects
• Languages: English
• ISBNs: 9783030470708
• Related ISBNs: 9783030470692
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