Charting by Chaplains in Healthcare

White Paper of the European Research Institute for Chaplains in HealthCare (ERICH)

Authors

  • Anne Vandenhoeck KU Leuven
  • Joost Verhoef OLVG General hospital
  • Daniel Nuzum Cork University Hospital & University College Cork
  • Pascal Mösli University of Zurich
  • David Neuhold University of Zurich
  • Simon Peng-Keller University of Zurich
  • Traugott Roser WWU Münster
  • Linda Ross University of South Wales
  • Wim Smeets Radboud UMC
  • Austyn Snowden Edinburgh Napier University
  • Wilfred McSherry Staffordshire University/University Hospitals of North Midlands NHS Trust

DOI:

https://doi.org/10.1558/hscc.20583

Keywords:

Spiritual Care, Healthcare Chaplaincy, charting spiritual care interventions

Abstract

“If it is not charted: it did not happen.” The charting of healthcare chaplaincy contacts in patient files has been controversially discussed in the literature in recent years. In particular, entries in digital medical records raise questions among pastoral care managers about confidentiality, data protection regulations and managerial interests.

The European White Paper on charting in healtcare chaplaincy argues that charting chaplaincy contacts with patients and relatives (1) makes their spiritual needs visible, (2) contributes to improved interprofessional communication about chaplaincy and (3) makes the work of chaplains transparant. Charting improves the quality of care for patients, promotes the professionalism of chaplaincy and facilitates interdisciplinary exchange and multi-professional cooperation. It should be noted that entries in patient files should be made as if the patient were reading them. Descriptions must be adequate, understandable and concrete: The reason for the contact, assessment, changes resulting from the contact, interventions made and further planning are five steps of patient-centred pastoral care documentation. They respect patient rights and the principles of clinical ethics. In each case, questions of the software used, access rights and the use of the collected data material need to be clarified.

The documentation of chaplaincy contacts can improve the relationship between patient and chaplain if it is included in the care. Last but not least, chaplaincy charting creates a data basis for practice-oriented research and training and for the development of the profession.

Author Biographies

  • Anne Vandenhoeck, KU Leuven

    Prof. Dr. Anne Vandenhoeck, Faculty of Theology and Religious Studies, KU Leuven, Belgium. 

  • Joost Verhoef, OLVG General hospital

    Dr. Joost Verhoef, OLVG General hospital, Amsterdam, The Netherlands.

  • Daniel Nuzum, Cork University Hospital & University College Cork

    Dr. Daniel Nuzum, Cork University Hospital & University College Cork, Ireland.

  • Pascal Mösli, University of Zurich

    Pascal Mösli, Faculty of Theology, Domain Spiritual Care, University of Zurich, Switzerland.

  • David Neuhold, University of Zurich

    Dr. David Neuhold, Faculty of Theology, Domain Spiritual Care, University of Zurich.

  • Simon Peng-Keller, University of Zurich

    Prof. Dr. Simon Peng-Keller, Faculty of Theology, University of Zurich, Switzerland.

  • Traugott Roser, WWU Münster

    Prof. Dr. Traugott Roser, Faculty of Protestant Theology, WWU Münster, Germany.

  • Linda Ross, University of South Wales

    Prof. Linda Ross, School of Care Sciences, Faculty of Life Sciences & Education, Pontypridd, Wales.

  • Wim Smeets, Radboud UMC

    Dr. Wim Smeets, Radboud UMC, Nijmegen, The Netherlands.

  • Austyn Snowden, Edinburgh Napier University

    Prof. Austyn Snowden, School of Health and Social Care, Edinburgh Napier University, United Kingdom.

  • Wilfred McSherry, Staffordshire University/University Hospitals of North Midlands NHS Trust

    Prof. Wilfred McSherry, School of Health, Science and Wellbeing, Staffordshire University/University Hospitals of North Midlands NHS Trust United Kingdom.

References

Balboni, T. A., Fitchett, G., Handzo, G. F., Johnson, K. S., Koenig, H. G., Pargament, K. I., Puchalski, C. M., Sinclair, S., Taylor, E. J., & Steinhauser, K. E. (2017). State of the science of spirituality and palliative care research part II: Screening, assessment, and interventions. Journal of Pain and Symptom Management, 54(3), 441–453. https://doi.org/10.1016/j.jpainsymman.2017.07.029

Burkhart, L. (2011). Documenting the story: Communication within a healthcare team, Vision, 21(3), 28–33.

Carey, L. B., & Cohen, J. (2015). The utility of the WHO ICD-10-AM pastoral intervention codings within religious, pastoral and spiritual care research. Journal of Religion and Health, 54(5), 1772–1787. https://doi.org/10.1007/s10943-014-9938-8

Dicks, R. L. (1940). Standards for the Work of the Chaplain in the General Hospital. Hospitals, November.

Galchutt, P., & Connolly, J. (2020). Palliative chaplain spiritual assessment progress notes. In Peng-Keller, S., Neuhold, D. (Eds.), Charting spiritual care: The emerging role of chaplaincy records in global healthcare (pp. 181–198). Cham: Springer. https://doi.org/10.1007/978-3-030-47070-8_11

Johnson, R. M., Wirpsa, J., Boyken, L., Sakumoto, M., Handzo, G., Kho, A., & Emanuel, L. (2016). Communicating chaplains’ care: Narrative documentation in a neuroscience-spine intensive care unit. Journal of Healthcare Chaplaincy, 22(4), 133–150. https://doi.org/10.1080/08854726.2016.1154717

Liégeois, A. (2010). Le conseiller spirituel et le partage d’informations en soins de santé. Un plaidoyer pour un secret professionnel partagé. Counseling et Spiritualité, 29(2), 85–97. https://resspir.org/wp-content/uploads/2018/11/Liégeois-Conseiller-spirituel-et-partage-dinformations-CounsSpirit-2010.pdf

Massey, K., Barnes, M., Villines, D., Goldstein, J., Pierson, A., Schere, C., Van der Laan, B., & Summerfelt, W. (2015). What do I do? Developing a taxonomy of chaplaincy activities and interventions for spiritual care in intensive care unit palliative care. BMC Palliative Care, 14(10), 1–8. https://doi.org/10.1186/s12904-015-0008-0

McCurdy, D. B. (2012). Chaplains, confidentiality and the chart. Chaplaincy Today, 28(2). https://doi.org/10.1080/10999183.2012.10767458

Ministère de la Santé et des Services sociaux du Québec (2010). Orientations ministérielles pour l’organisation du service d’animation spirituelle en établissements de santé et de services sociaux. Ministère de la santé et des services sociaux du Québec.

Montonye, M., & Calderone, S. (2010). Pastoral interventions and the influence of self-reporting: A preliminary analysis, Journal of Healthcare Chaplaincy, 16, 65–73. https://doi.org/10.1080/08854720903519976

Mösli, P., Neuhold, D., & Wey-Meier, L. (2020). Ankreuzen oder erzählen? Ein Plädoyer für Check-Boxes in der klinischen Seelsorgedokumentation. In Peng-Keller, S., Neuhold, D., Kunz, R., & Schmitt, H. (Eds.), Dokumentation als seelsorgliche Aufgabe. Elektronische Patientendossiers im Kontext von Spiritual Care (pp. 127–149). Zürich: TVZ. https://www.tvz-verlag.ch/_files_media/open_access/9783290183264.pdf

Peng-Keller, S., & Neuhold, D. (Eds.) (2020). Charting spiritual care: The emerging role of chaplaincy records in global healthcare. Zurich: Springer Nature. https://doi.org/10.1007/978-3-030-47070-8

Richards, S., Carlson, K., Matthias, T., & Birge, J. (2021). Perception versus reality: Does provider documentation behavior change when clinic notes are shared electronically with patients? International Journal of Medical Informatics, 145, 104304. https://doi.org/10.1016/j.ijmedinf.2020.104304

Rosell, T. D. (2006). Pastoral products or pastoral care? How marketplace language affects ministry in veterans hospitals. Journal of Pastoral Care and Counseling, 60(4), 363–367. https://doi.org/10.1177/154230500606000405

Ross, L., Grimwade, L., & Eagger, S. (in press). Spiritual Assessment. In Cook, C. C. H., & Powell, A. (Eds.) Spirituality and Psychiatry, 2nd Edn. Cambridge: Cambridge University Press.

Ross, L., & McSherry, W. (2010). Considerations for the future of spiritual assessment. In McSherry, W., & Ross, L. (Eds.) Spiritual assessment in healthcare practice (pp. 161–171). Keswick: M&K Publishing.

Ross, L., & McSherry, W. (2018). The power of two simple questions. Nursing Standard, 33(9), 78–80. https://doi.org/10.7748/ns.33.9.78.s22

Ross, L., & McSherry, W. (2020). Spiritual care charting/documenting/recording/assessment: A perspective from the United Kingdom. In Peng-Keller, S., & Neuhold, D. (Eds.) Charting spiritual care: The emerging role of chaplaincy records in global healthcare (pp. 153–171). Cham: Springer. https://link.springer.com/content/pdf/10.1007%2F978-3-030-47070-8.pdf

Ross, L., & Miles, J. (2020). Spirituality in heart failure: A review of the literature from 2014 to 2019 to identify spiritual care needs and spiritual interventions. Current Opinion in Supportive and Palliative Care, 14(1), 9–18. https://doi.org/10.1097/SPC.0000000000000475

Ruff, R. A. (1996). “Leaving footprints.” The practice and benefits of hospital chaplains documenting pastoral care activities in patients’ medical records. Journal of Pastoral Care and Counseling, 50(4), 383–391. https://doi.org/10.1177/002234099605000407

Smeets, W., Gribnau, F. W. J., & van der Ven, J. A. (2011). Quality assurance and spiritual care. Journal of Empirical Theology, 24(1), 80–121. https://doi.org/10.1007/978-3-030-47070-8_7

Smeets, W., & de Vries, A. (2016). Spiritual screening in a secular context. In Elsdörfer, U., & Ito, T. D. (Eds.), Compassion for one another in the global village. Social and cultural approaches to care and counselling (pp. 92–99). Wien: LIT.

Smeets, W., & de Vries, A. (2020). Spiritual care and electronic medical recording in Dutch hospitals. In Peng-Keller, S., & Neuhold, D. (Eds.), Charting spiritual care: The emerging role of chaplaincy records in global healthcare (pp. 117–125). Cham: Springer. https://link.springer.com/content/pdf/10.1007%2F978-3-030-47070-8.pdf

Snowden, A., Enang, I., Kernohan, W. G., Fraser, D., Gibbon, A., Macritchie, I., McSherry, W., Ross, L., & Swinton, J. (2020). Why are some healthcare chaplains registered professionals and some are not? A survey of healthcare chaplains in Scotland. Journal of Health and Social Care Chaplaincy, 8(1), 45–69. https://doi.org/10.1558/hscc.39783

Snowden, A., & Telfer, I. (2017). Patient reported outcome measure of spiritual care as delivered by chaplains. Journal of Healthcare Chaplaincy, 23(4), 131–155. https://doi.org/10.1080/08854726.2017.1279935

Springer Loewy. R., & Loewy, E. H. (2007). Healthcare and the Hospital Chaplain. Medscape General Medicine, 9(1). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924976/

Steinhauser, K. E., Fitchett, G., Handzo, G. F., Johnson, K. S., Koenig, H. G., Pargament, K. I., Puchalski, C. M., Sinclair, S., Taylor, E. J., & Balboni, T. A. (2017). State of the science of spirituality and palliative care research part I: Definitions, measurement, and outcomes. Journal of Pain and Symptom Management, 54(3), 428–440. https://doi.org/10.1016/j.jpainsymman.2017.07.028

Tschannen, O., Chenuz, P., Maire, D. E., Petremand, D., Vollenweider, P., & Odier, C. (2014). Transmission d’informations par les aumôniers dans le dossier-patient: le choix des patients. Forum Med Suisse, 14(49), 924–926.

Vandenhoeck, A. (2020). The spiritual care giver as a bearer of stories: A Belgian exploration of the best possible spiritual care. In Peng-Keller, S., & Neuhold, D. (Eds.), Charting spiritual care: The emerging role of chaplaincy records in global healthcare (pp. 129–144). Cham: Springer. https://doi.org/10.1007/978-3-030-47070-8_8

Wintz, S., & Handzo, G. (2015). Dokumentation und Verschwiegenheit in der professionellen Seelsorge. Wege zum Menschen, 67(2), 160–164. (English version at http://www.handzoconsulting.com/blog/2013/9/19/documentation-and-confidentiality-for-chaplains.html.)

World Health Organization (2002). ICD-10 AM International Statistical Classification of Diseases and Related Health Problems 10th Revision Australian Modification. World Health Organization.

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Published

2022-01-28

How to Cite

Vandenhoeck, A. ., Verhoef, J. ., Nuzum, D. ., Mösli, P. ., Neuhold, D. ., Roser, T. ., Ross, L. ., Smeets, W. ., Snowden, A., & McSherry, W. . (2022). Charting by Chaplains in Healthcare: White Paper of the European Research Institute for Chaplains in HealthCare (ERICH). Health and Social Care Chaplaincy, 10(1), 50–77. https://doi.org/10.1558/hscc.20583