Gordon J. Hilsman Franciscan Health System Tacoma WA January 8, 2009

Charting Basics Assessment Elements Assessment Framework Q & A Presentation Roadmap

Objectives How to: Engage the art of creating practically useable notes in the medical record Use basic assessment elements to create a chart form Progressively clarify your own assessment framework

Basic Assumptions Charting is an art Charts are legal documents Medical professionals do read chaplain notes Patients have access to their own medical record A culture of confidentiality promotes self disclosure Assessment is a partnership Recorded assessment consolidates spiritual care responsibility Legibility is essential

Chart Note Elements 1. What – Title - Pastoral Care (Spiritual Care) 2. When – Date / Time (24 hour clock) 3. Who – The Patient 4. Why you met this person 5. (Why she is hospitalized) 6. How she related to you in the encounter 7. What – Issues – Assessment descriptions/concepts 8. What – Chaplain functions - performed for this person 9. What – Plan – What you will do for this person 10. Who – You - Signature & professional identity

Fashioning Sentences Purpose - I saw this patient (reason you met her) Description - This (the patient) is a (age) (marital status) (race)(gender) who (reason for approaching the health care system) Process - She (phenomenological impressions of her and how she related to you) Assessment One – She (Your perceptions of what is now tending to sink her human spirit) Assessment Two - She (sources adding buoyancy to her spirit) Assessment Three – Her relationship to the Transcendent and the established world of religions and/or elements of her unique spirituality Functions - I (what the chaplain did to assist her spirit) Plan - I will (What this chaplain will do to further assist her)

I saw this patient at the request of her father who I had met in the hallway. She is a 57 year old widowed Pilipino woman with a daughter in California and a son that lives in town. She spoke in sad tones about her nagging knee pain and her mother who died in February. She has been crying this morning, somewhat overwhelmed by her inability to lift her grandson and by her grief over her mother’s death. I listened, facilitated her grieving and prayed with her, though she is currently not practicing her Catholic heritage. I will suggest the evening chaplain drop in on her for further support. She declined being visited by a priest.

Assessment Elements Spiritual Needs Chaplain Functions Chaplain Functions Pastoral Care Outcomes

An example of a chaplain- fashioned spiritual assessment and charting system that has been successful for one health care system

Assessment Framework A minimal structure of concepts on which a chaplain can organize observations and impressions of spiritual issues that are potentially related to a person’s spiritual wellbeing.

ASSESSINGASSESSING 6.Grief Support 7.Grief Counseling 8. End of Life Care 9. Adjustment Counseling 16. Ethics Consulting 17. Family Systems Facilitating 18. Advocacy 19. Mental Health/Addictions Consult 20. Family Behavioral Concerns 21. Love Life Consulting. 10. Instructing 11. Religious Support 12. Spiritual Support 13. Spiritual Counseling 14. Self- Forgiveness 15. Healing Estrangement Screening for Spiritual Pathologies Loss / Adjustment Spiritual / Religious Support Advocacy /Referral /Ethics Establishing Rapport Emotional Support Careful Listening Empathic Reflecting Gentle Querying Insightful Interpreting 1. Crisis Ministry 2. Supportive/Validating 3. Informing 4. Presence and Networking 5. Empowering

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Spiritual Assessment Form What are the needs? What did we provide? What is the plan of care?

Basic Axis Questions  What does this person need emotionally right now?  What has this person lost, recently and historically?  What are the ways this person maintains and nurtures her own human spirit?  What does this person need that may be beyond my relationship with him?  Are there “spiritual pathologies” that have severely damaged or even precluded this person’s spiritual development?

Axis One: Emotional Support What does this person need emotionally right now, (from me)? 15 (Mad, Sad, Glad, Hurt, Afraid, Ashamed)

1. The Crisis Need for Stabilizing EMOTIONAL SUPPORT 2. The Expression Need to Engage and Share 3. The Anxious Need of Waiting Too Long 4. The Bewildering Need for Basic Information 5. The Regression Need to be Empowered

1 - Stabilizing - Personal support when familiar patterns are disrupted by crisis events Helping people pull themselves together

2. The Expression Need to Engage and Share Supportive validating (listening) the Need to cry, yell, share, or just tell somebody how you feel about what is happening to you

19 2. An Expressing person Supportive Validating Talks openly Expresses Feelings Cries Relaxes Considers Resources Function Desired Outcomes

3-Information Need for basic information Informing in the wilderness of healthcare systems

4 - W a i t i n g Upset feelings from waiting too long in an important situation Presence and Networking

22 4. A person who is waiting too long Presence & Networking Expresses situation Acknowledges health care system limitations Prays Expresses Gratefulness Calm Function Desired Outcomes

5-Helping Yourself Heal - Need to find and use your own best ways of dealing with difficult times Helping people extricate themselves from regressing after being overwhelmed

Axis Two: Loss and Grief What has this person lost, recently and historically, that still disturbs her/him at times?

Loss 6-Acute Grief (Past 48 hrs) 7-Prior Grief8.Dying 9-Life Adjustment

6 - Current Grief Major loss in previous 48 hours Facilitating saying goodbye to somebody recently lost

7 - Prior Grief Major past loss being currently grieved Recognizing current warm-sad memories and facilitating the past loss grief that enkindled them

28 7. Prior Grief Grief Counseling Mentions previous loss Expresses emotion Receives validation Shares reminiscences Cries while talking about the lost loved one Receives referral for further grief assistance Expresses greater hope Function Desired Outcomes

Grief Counseling Outcomes (%)

8 - Dying Dealing with the goodbyes of the dying process Helping people say goodbye when they’re dying

9-Life adjustment Making peace with a major change in appearance or function Getting used to the new way things will be

Axis Three: Spiritual Resources How does this person maintain and nurture her own human spirit? 32

33 Religious/ Spiritual Care 10. Instruction 11. Religious Support 12. Spiritual Support 13. Spiritual Counsel 14. Self Forgiveness 15. Estrangement

ASSESSINGASSESSING 6.Grief Support 7.Grief Counseling 8. End of Life Care 9. Adjustment Counseling 16. Ethics Consulting 17. Family Systems Facilitating 18. Advocacy 19. Mental Health/Addictions Referral 20. Family Behavioral Concerns 21. Love Life Consulting. 10. Instructing 11. Religious Support 12. Spiritual Validation 13. Spiritual Counseling 14. Self- Forgiveness 15. Healing Estrangement Screening for Spiritual Pathologies Loss / Adjustment Spiritual / Religious Support Advocacy /Referral /Ethics Establishing Rapport Emotional Support Careful Listening Empathic Reflecting Gentle Querying Insightful Interpreting 1. Crisis Ministry 2. Supportive/Validating 3. Informing 4. Presence and Networking 5. Empowering

10 – Religious and Spiritual Instruction Need to learn religious/self care modalities

11 - Religious Support - Needing to feel the immediate positive presence of Transcendence “I want to feel God all around me!” 36

37 Person who is needing God Religious Support Sacrament/ spiritual ritual Spiritual leader of choice Religious questions/problems Prays Desired Outcomes Function

12 - Spiritual Support - Need to share unique ways one nurtures one’s human spirit “Let me tell you about what I do and believe that deeply feeds me personally!”

13 - Spiritual Counseling - Mulling – The Need to discuss ultimate matters, and/or heal old religious wounds “What I want to know is ….” “What really turned me off ….” “I couldn’t believe it when….”

14. Self-Forgiveness Need for relief from guilt or shame “I did that and I’ve never told anyone!”

15 – Estrangement - Need to re-connect with relationally separated loved ones Wanting to get back together with somebody you love.

43 A person regretting estrangement Function Desired Outcomes Reconciling Talks with emotion about an estranged relationship Agrees to receive contact with an estranged person Agrees to take initiative to contact an estranged person Accepts the adequacy of one’s efforts at reconciling

Axis Four: Advocacy and Referral What does this person need that may be beyond my relationship with her/him?

45 Referral/ Ethics 16. Medical Ethics Concerns 17. Family Conflict 18. Advocacy 19. M. Health/ Addiction Concerns 20. Family Dysfunction Concerns 21. Love Life

16 - Ethics Questions - Need to understand or discuss treatment outcome concerns Begin the process of using professional help to sort out options when there is no clear best care direction

17 - Family Conflict – Needing help with upset feelings among family members Facilitating healing/referral of family conflict

18 – Advocacy Need for support in finding appropriate care Feeling neglected

Mental Health/Addictions - Need to explore concerns about one’s mental health or mood altering chemical abuse

50 19.Person with mental illness or addiction concerns Function Desired Outcomes Referral Concern verbalized Feelings expressed Calm conversation Accepts consultation

20 - Family Mental Health/Addiction Concerns Need to address concerns about behavior of a family member

Love Life Pain Need for listening, advice or referral about one’s love life

ASSESSINGASSESSING 6.Grief Support 7.Grief Counseling 8. End of Life Care 9. Adjustment Counseling 16. Ethics Consulting 17. Family Systems Facilitating 18. Advocacy 19. Mental Health/Addictions Referral 20. Family Behavioral Concerns 21. Love Life Consulting. 10. Instructing 11. Religious Support 12. Spiritual Validation 13. Spiritual Counseling 14. Self- Forgiveness 15. Healing Estrangement Screening for Spiritual Pathologies Loss / Adjustment Spiritual / Religious Support Advocacy /Referral /Ethics Establishing Rapport Emotional Support Careful Listening Empathic Reflecting Gentle Querying Insightful Interpreting 1. Crisis Ministry 2. Supportive/Validating 3. Informing 4. Presence and Networking 5. Empowering

Questions / Discussion

Finis