© BRIDGEPOINT Charting as a Spiritual Practice: The art & science of charting CASC convention, Toronto, Ontario April 2011 Jan Kraus, Spiritual Care Department

© BRIDGEPOINT 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 Spiritual Practice

© BRIDGEPOINT 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

© BRIDGEPOINT To serve the patient To serve the team Benefits

© BRIDGEPOINT To Serve the Patient: To record our assessment and intervention To build an appropriate plan To provide continuity

© BRIDGEPOINT To protect the patient from unwanted service/rituals To provide accountability to the patient To provide opportunity for education/growth To Serve the Patient:

© BRIDGEPOINT To Serve the Team: To advocate To educate To share insight To humanize the hospitalization To engage in research To identify funding needs

© BRIDGEPOINT 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

© BRIDGEPOINT But …..how do I do it ???????

© BRIDGEPOINT

© BRIDGEPOINT Pause, take a deep breath One step at a time

© BRIDGEPOINT Grab your Guidelines Remember Your CPE tools Pruyser, Fitchett & friends

© BRIDGEPOINT Story Telling Our chart notes help tell the patient’s story Professional Story Teller

© BRIDGEPOINT 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

© BRIDGEPOINT What did you observe? What did the patient tell you? What was your intervention? How did the patient (family member) respond to your intervention? More questions

© BRIDGEPOINT 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

© BRIDGEPOINT 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?

© BRIDGEPOINT Action, reflection, new action Spiritu al care Plan Data Spiritual Analysis

© BRIDGEPOINT 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

© BRIDGEPOINT 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

© BRIDGEPOINT 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

© BRIDGEPOINT 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 Analysis

© BRIDGEPOINT Analysis In what ways do you see the spiritual issue impacting the patient’s physical and emotional health? Spirit Mind Body

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

© BRIDGEPOINT ACTION VERBS Addressed Affirmed Arranged Assessed Created Communicated Educated Encouraged Engaged Explored Facilitated Invited Informed Offered Prayed Provided Promoted Read Supported Searched Action Verbs

© BRIDGEPOINT 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

© BRIDGEPOINT 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

© BRIDGEPOINT Educated about.. spiritual care services commonalities of human response to loss, crisis or illness (normalizing) Encouraged verbalize of experience of hospitalization and illness More Examples

© BRIDGEPOINT Examples of phrases that reflect our practice Engaged in active listening; in building a therapeutic relationship in cognitive re-structuring in life review Explored pt’s belief system and how it impacts their healing process Examples of phrases that reflect our practice

© BRIDGEPOINT Facilitated contact with; a local faith community/leader family meeting communication between the family members Informed about spiritual care services available to the pt/ how to contact a chaplain More Examples

© BRIDGEPOINT Invited pt to express their feelings of … Prayed with the pt/family per pt. request for … forgiveness, healing, acceptance, etc… More Examples

© BRIDGEPOINT 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

© BRIDGEPOINT Read Sacred Scriptures as per pt. request Supported pt’s expression of feelings of … religious and spiritual beliefs practices religious doubt More Examples

© BRIDGEPOINT 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

© BRIDGEPOINT 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

© BRIDGEPOINT 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

© BRIDGEPOINT 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!

© BRIDGEPOINT Variations Charting is like walking a labyrinth Spiritual practice

© BRIDGEPOINT Focus note Focus: Spiritual/Cultural Data: Analysis: Action: Response: Plan: Your signature and title Focus Note

© BRIDGEPOINT Contact Jan K. Kraus, M. Div –Manager, Spiritual Care Department Bridgepoint Health –CASC Specialist in Institutional Ministry –CASC Teaching Supervisor – x 2172