EVALUATING DOCUMENTATION QUALITY Carolanne Hauck, MA, BCC Director of Chaplaincy Care and Education, Lancaster General Health, Lancaster, PA Beverly M Beltramo, D.Min, BCC Director of Spiritual Support, Oakwood Healthcare System, Dearborn, MI

THE EMR TEAM

IMPORTANCE OF DOCUMENTATION

WORKING TOGETHER Standard evaluation for quality even though we use different assessments. Is that possible?

MATRIX 1 - incomplete2 - thorough3 – effective Spiritual Assessment  Faith  Coping  Sources of Strength  Fears/Concern Identified Implications for Care  Relevance to Care Team  Follow-up Narrative  Clarity  Brevity  Professionalism

OAKWOOD HEALTHCARE Spiritual Care Assessment Visit with : * Patient declines visit * Patient * Patient & Family * Family Only * Other: *** Reason for Visit: * Initial Visit * Follow up Visit * Crisis/Urgent * Hospice/PRISM * Advanced Directive Assistance * Consult from *** ASSESSMENT Patient’s Spiritual Issues : * Despair/loss of hope * Forgiveness/seeking reconciliation * Grief or loss (actual or anticipatory) * Isolation/Alienation * Abandonment/disconnect from God * Lack of social/family support * Loss of meaning/purpose * Advanced Directives * * Addiction Issues * End of Life Support * Mental Health Issues * Spiritual Distress * Family Concerns * Acceptance * * Unresolved Anger * Other: *** Patient’s Sources of Strength/Support * Gratitude * Positive attitude * Wisdom * Peace * Hope * Acceptance * Sense of humor * Strong religious faith * Family * Friends * Faith Community * Other: *** Distress/Suffering : Patient’s REPORTED/ASSESSED level of suffering or distress: Worries/Concerns/Fears: *** PLAN: SPIRITUAL INTERVENTIONS/RECOMMENDATIONS * Active listening/Supportive dialogue * Educated: Advance Directives * Educated: Bereavement Resources/grief process * Educated: Spiritual Practices/resources * Explored beliefs/values/coping * Explored End of life issues F * Facilitated Family Communication * Facilitated Expression of Emotions * Facilitated Life Review * Provided Prayer/Sacred Text /Ritual * Provided Relaxation techniques * Provided Spread the Love Blanket * Sacramental Anointing (Last Rites) * Sacrament: Holy Communion * Supported Expression of grief * Other: *** Interventions Narrative: *** OUTCOMES * Acceptance expressed * Affect changed * Connection with treatment team improved * Increased coping * Cultural Religious Needs supported * Expressed Sense of Meaning * Feelings Expressed * Gratitude Expressed * Grieving facilitated/expressed * Guilt/forgiveness addressed * Hope identified/restored * No Change * Patient declined further spiritual support * Sense of meaning expressed ISSUES TO BE ADDRESSED IN A FUTURE ENCOUNTER * Limited Social/ Family Support * Exploring Beliefs * Faith Community engagement * Faith Community Estrangement * Family/relationship needs * Financial/Social concerns * Forgiveness/Reconciliation * Guilt/Shame * Grief and loss * Ritual or Sacramental Needs * Spiritual/emotional distress * End of Life care * Extended Length of stay * Palliative or Hospice patient

EXAMPLE Visit with: Patient Reason for Visit: Follow up Visit ASSESSMENT Patient's Spiritual Issues: Other: Patient sitting in chair but intubated and unable to talk. Patient communicated with facial expressions and her eyes and requested prayer Patient's Sources of Strength/Support: Other: Unable to discern Distress/Suffering (Patient assessed level of suffering/distress): 8 out of 10 Worries/Concerns/Fears: Patient was alert and somewhat oriented. Patient nodded yes when I told her who I was. Patient again nodded yes when I asked if she'd like me to pray for her. No others were in the room. PLAN: SPIRITUAL INTERVENTIONS/RECOMMENDATIONS Current intervention: Explored beliefs/values/coping, Provided Prayer/Sacred Text /Ritual and Supportive presence Outcomes: Gratitude Expressed via eye communication Issues to be Addressed in a Future Encounter: Extended Length of stay I will provide continuing pastoral interventions.

MATRIX 1 - incomplete2 - thorough3 – effective Spiritual Assessment  Faith  Coping  Sources of Strength  Fears/Concerns Identified Unable to assess very well, given that patient was unable to speak, though she did communicate quite well non- verbally. Implications for Care  Relevance to Care Team  Follow-up Perhaps can help team slow down and take time to allow her to communicate with them. Narrative  Clarity  Brevity  Professionalism Note well written. Perhaps more narrative?

Example #2 Visit with: Patient & Family Reason for Visit: Initial Visit ASSESSMENT Patient's Spiritual Issues: Other: Patient not responsive to my visit but son Larry was bedside. He said the patient was Assembly of God Christian. Patient's Sources of Strength/Support: (Per son) Strong religious faith, Family, Friends and Faith Community Distress/Suffering (Patient assessed level of suffering/distress): 6 out of 10 Worries/Concerns/Fears: Son is of opinion that patient is waking up. Hopeful for a full recovery for his dad. Son said Patient's church is _______Assembly of God. Son said he'd contact patient's pastor for a visit. Son also a member there. PLAN: SPIRITUAL INTERVENTIONS/RECOMMENDATIONS Current intervention: Active listening/Supportive dialogue, Explored beliefs/values/coping and Provided Prayer/Sacred Text read. Outcomes: Gratitude Expressed. Son was complimentary of the excellent care being provided by the hospital and medical staff. Son expects patient to awaken and leave the hospital soon. Patient does need to talk to the doctor about the new diagnosis of heart attack he has heard. Issues to be Addressed in a Future Encounter: Exploring Beliefs and possible “new normal.”

MATRIX 1 - incomplete2 - thorough3 – effective Spiritual Assessment  Faith  Coping  Sources of Strength  Fears/Concerns Identified Perhaps focused too much on faith? Solid conversation about strengths and faith Implications for Care  Relevance to Care Team  Follow-up Will help staff to know son’s expectations, also will help to know patient has strong religious belief. They will appreciate son’s positive feedback. Narrative  Clarity  Brevity  Professionalism Clear language, written well.

LANCASTER GENERAL HEALTH Chaplaincy Care Note : How did you select this pt? i.e. consult from [name], [title]; self-initiated based on…; pt requested visit; etc. Assessment : identify the spiritual risks, concerns, or struggles as well as the spiritual resources that the patient and/or family bring to this current hospitalization. Consider these areas: life review, hopes, values, fear, meaning purpose, beliefs about afterlife, spiritual or religious practices, and cultural norms, beliefs that influence understanding of illness, loss history, coping, guilt, forgiveness, and life completion tasks. Goals for Spiritual Care: Given the above assessment, what are the goals for the patient or family during this hospitalization? Interventions: How did you work towards these Goals during the visit? Outcomes: What were the results of your visit? How did patient or family respond? Describe behavioral changes to that indicate response. Was there progress toward the goals? Is there more work to be done toward the goals? If so, how will that be done? Follow-up needed?

EXAMPLE 1 LGH Assessment: Patient is grieving mastectomy and now the impending loss of fertility and her child-rearing days. History of childhood abuse is contributing to confusing feelings about changes in body image and sexual intimacy. Faith is very important aspect of spiritual life. Pt is seeking Catholic perspective on moral / ethical dimensions of hysterectomy prior to making decision. Patient’s husband is very supportive.

MATRIX 1 - incomplete2 - thorough3 – effective Spiritual Assessment  Faith  Coping  Sources of Strength  Fears/Concerns Identified Catholic Actively grieving Faith, spouse Ethical aspects, sexual intimacy, past hx of abuse Implications for Care  Relevance to Care Team  Follow-up Follow-up not noted Good for team to know spiritual and emotional side Narrative  Clarity  Brevity  Professionalism Succinct clear and to the point

TEST PILOT FEEDBACK Positives Method for evaluation Most evaluations matched on 4 samples Sparked some good discussion Good tool to help students learn to chart Negatives As is: only good for Assessment Did not like thorough prefer adequate Would like a description of “effective” and “thorough” Not entirely clear how to use—several different interpretations

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