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Charting as a Spiritual Practice: The art & science of charting CASC convention, Toronto, Ontario April 2011 Jan Kraus, Spiritual Care Department. Spiritual Practice. Focus A habit that brings you back to the Divine and opens you up to the ways in which the Divine is present

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Spiritual practice

Chartingas a Spiritual Practice:The art & science of chartingCASC convention, Toronto, OntarioApril 2011Jan Kraus, Spiritual Care Department


Spiritual practice

Spiritual Practice

  • 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


Why bother

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


Spiritual practice

To serve the patient

To serve the team

Benefits


To serve the patient

To Serve the Patient:

To record our assessment and intervention

To build an appropriate plan

To provide continuity


To serve the patient1

To Serve the Patient:

  • To protect the patient from unwanted service/rituals

  • To provide accountability to the patient

  • To provide opportunity for education/growth


To serve the team

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

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


Spiritual practice

But …..how do I do it ???????


Spiritual practice

Pause, take a deep breath

  • One step at a time


Spiritual practice

Grab your Guidelines

  • Remember

  • Your CPE tools

  • Pruyser, Fitchett & friends


Story telling

Story Telling

Professional Story Teller

  • Our chart notes help tell the patient’s story


Questions to ask yourself before charting

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


More questions

More questions

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

  • What was your intervention?

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


Questions to ask yourself before charting1

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

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

Action, reflection, new action

Spiritual Analysis


Spiritual practice

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


Spiritual practice

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

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


Analysis1

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


Analysis2

Analysis

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


Action

Action

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

Action


Action verbs

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

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


Examples of phrases that reflect our practice

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…

Examples of phrases that reflect our practice


More examples

More Examples

  • Educated about ..

    spiritual care services

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

  • Encouraged verbalize of experience of hospitalization and illness


Examples of phrases that reflect our practice1

Examples of phrases that reflect our practice

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

Examples of phrases that reflect our practice


More examples1

More Examples

  • 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 examples2

More Examples

  • Invited pt to express their feelings of …

  • Prayed with the pt/family per pt. request for … forgiveness, healing, acceptance, etc…


Examples of phrases that reflect our practice2

Examples of phrases that reflect our practice

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

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

Examples of phrases that reflect our practice


More examples3

More Examples

  • Read Sacred Scriptures as per pt. request

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


Examples of phrases that reflect our practice3

Examples of phrases that reflect our practice

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)

Examples of phrases that reflect our practice


Response

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


Spiritual practice

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

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

Variations

Spiritual practice

  • Charting is like walking a labyrinth


Focus note

Focus note

Focus: Spiritual/Cultural

Data:

Analysis:

Action:

Response:

Plan:

Your signature and title

Focus Note


Contact

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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