The development of an outcome oriented and research informed spiritual care assessment and documentation form for the electronic health record in an adult hospital setting.

Abstract

Standards for professional chaplaincy expect chaplains to document their work in patients' medical records, but no agreed upon standard for the content or format of such documentation exists. With the adoption of Electronic Health Records (EHRs) in many hospitals, chaplains may utilize a provided electronic form or one that can be customized from a basic format to departmental specifications. Ideally, the documentation form supports and reflects the work of chaplains in their specific clinical context. Outcome oriented models of chaplaincy and an increasing focus on a research informed practice of spiritual care should determine the format and content of chaplains' documentation in the EHR. This article describes how a chaplaincy department in an adult academic Level I trauma center designed and implemented a spiritual care documentation form for the EHR. The documentation template is informed by clinical expertise and by research about patients' meaning-making activities and patients' experience of connectedness in the context of illness. It integrates a consensus-based assessment form with narrative documentation options, searchable selections, and an outcome-oriented plan of care.