ABCs of Hospital Chaplaincy: C is for Charting

When I began my first unit of CPE, way back in 2006, I remember the awesome sense of responsibility I had each time I got to document one of my patient visits. I can’t believe we get to write in the patients’ charts, I thought, just like doctors do! Over the next several years and hundreds, maybe thousands of visits, charting became much less exciting. It was part of the routine, something to check off the list of tasks that must be done. “If you didn’t chart it, it didn’t happen,” my CPE supervisor told us. So I charted my visits, over and over and over again. Every job involves paperwork, I suppose, and this is ours. (And yes, when I started out, most of the charting we did was still on paper, writing with an actual pen on a form in a binder. It’s all electronic now.) 

This summer, when our hospital transitioned to a new electronic charting system, I had the opportunity to think about things differently. What had become routine was suddenly new again. And since this system was being built from the ground up, each department had the opportunity to contribute our own ideas to its design. What information did we want included in the section dedicated to chaplains’ input? What did we think would be necessary for other members of each patient’s care team to know about the work we had done with that patient? How could we make clear the importance of our contribution as professionals, when what we provide is not as easily quantifiable as medication or surgical interventions or physical therapy?

For the most part, I like what our staff came up with for the spiritual care assessment section of the electronic chart. It’s still a work in progress, but we’ve made a good start. It gives us a chance to share information that could be helpful to other staff, such as the patient’s anxiety level (which they may be more honest about with the chaplain than with others), any religious or cultural factors that could influence their treatment (such as a Muslim patient who wants to fast during daylight hours for Ramadan, if at all possible), what their sources of hope are and how they are coping with this hospitalization, who their community is (family, friends, members of a religious group who may offer needed support during and after their stay), any religious/spiritual practices important to them that may be helpful (prayer and meditation may calm anxiety, for example), what gives their life meaning and how this illness or injury may affect that, their hopes for the future (which may have to be adjusted now that they are sick or hurt), how their beliefs influence how they view their current situation (such as patients who believe God is punishing them for some sin with this illness).

Our pastoral care department also has a separate internal charting system, which only other chaplains can access. Some of the information there is simply for us to keep track of what kinds of calls we get — how many traumas, how many advance directive requests, how many deaths, how many codes, how many pre-surgery prayers, etc. — and what time of day they come in, which chaplain responded and how long she/he was there. Other information gives a heads-up to the chaplain on the following shift that this patient is actively dying, this one does not want a female chaplain, this one is Catholic and requesting the eucharist tomorrow, this patient’s family may react with anger if they receive bad news, this one wants someone to come pray with her every day if possible. If there is a special need for follow-up, we put that patient on our “red star” list, to make sure the next chaplain is aware of him or her. If there is an unfinished advance directive visit to take care of, that goes on the “green star” list. I know to check these lists as soon as I get to work, in addition to any referrals that come in from medical staff via the new charting system, Epic.

All in all, charting is not an exciting part of the job for me anymore. There are some days when I have to give myself a pep talk because it seems like such a chore. But I am still glad, when I think about it, that we get to write in the patients’ (now electronic) charts, just like the doctors, and nurses, and social workers, and physical therapists, and child life specialists, and many others. We are part of the team, in a hospital system that recognizes the need to treat the whole person, not just the physical symptoms of a disease or injury. For that, I am thankful.

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2 thoughts on “ABCs of Hospital Chaplaincy: C is for Charting

  1. Mary Ruth Warren

    Nice post! I enjoyed getting to take a look at what your job (and the Chaplain in our facility) looks like from a charting perspective 🙂 Mary Ruth

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