1. © BRIDGEPOINT 2006 1 Charting as a Spiritual Practice: The art & science of charting CASC convention, Toronto, Ontario April 2011 Jan Kraus, Spiritual Care Department

2. © BRIDGEPOINT 2006 2 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

3. © BRIDGEPOINT 2006 3 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

4. © BRIDGEPOINT 2006 4 To serve the patient To serve the team Benefits

5. © BRIDGEPOINT 2006 5 To Serve the Patient: To record our assessment and intervention To build an appropriate plan To provide continuity

6. © BRIDGEPOINT 2006 6 To protect the patient from unwanted service/rituals To provide accountability to the patient To provide opportunity for education/growth To Serve the Patient:

7. © BRIDGEPOINT 2006 7 To Serve the Team: To advocate To educate To share insight To humanize the hospitalization To engage in research To identify funding needs

8. © BRIDGEPOINT 2006 8 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

9. © BRIDGEPOINT 2006 9 But …..how do I do it ???????

10. © BRIDGEPOINT 2006 10

11. © BRIDGEPOINT 2006 11 Pause, take a deep breath One step at a time

12. © BRIDGEPOINT 2006 12 Grab your Guidelines Remember Your CPE tools Pruyser, Fitchett & friends

13. © BRIDGEPOINT 2006 13 Story Telling Our chart notes help tell the patient’s story Professional Story Teller

14. © BRIDGEPOINT 2006 14 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

15. © BRIDGEPOINT 2006 15 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

16. © BRIDGEPOINT 2006 16 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

17. © BRIDGEPOINT 2006 17 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?

18. © BRIDGEPOINT 2006 18 Action, reflection, new action Spiritu al care Plan Data Spiritual Analysis

19. © BRIDGEPOINT 2006 19 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

20. © BRIDGEPOINT 2006 20 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

21. © BRIDGEPOINT 2006 21 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

22. © BRIDGEPOINT 2006 22 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

23. © BRIDGEPOINT 2006 23 Analysis In what ways do you see the spiritual issue impacting the patient’s physical and emotional health? Spirit Mind Body

24. © BRIDGEPOINT 2006 24 Action Use ACTION VERBS to describe your intervention What did you do? Action

25. © BRIDGEPOINT 2006 25 ACTION VERBS Addressed Affirmed Arranged Assessed Created Communicated Educated Encouraged Engaged Explored Facilitated Invited Informed Offered Prayed Provided Promoted Read Supported Searched Action Verbs

26. © BRIDGEPOINT 2006 26 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

27. © BRIDGEPOINT 2006 27 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

28. © BRIDGEPOINT 2006 28 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

29. © BRIDGEPOINT 2006 29 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

30. © BRIDGEPOINT 2006 30 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

31. © BRIDGEPOINT 2006 31 Invited pt to express their feelings of … Prayed with the pt/family per pt. request for … forgiveness, healing, acceptance, etc… More Examples

32. © BRIDGEPOINT 2006 32 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

33. © BRIDGEPOINT 2006 33 Read Sacred Scriptures as per pt. request Supported pt’s expression of feelings of … religious and spiritual beliefs practices religious doubt More Examples

34. © BRIDGEPOINT 2006 34 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

35. © BRIDGEPOINT 2006 35 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

36. © BRIDGEPOINT 2006 36 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

37. © BRIDGEPOINT 2006 37 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!

38. © BRIDGEPOINT 2006 38 Variations Charting is like walking a labyrinth Spiritual practice

39. © BRIDGEPOINT 2006 39 Focus note Focus: Spiritual/Cultural Data: Analysis: Action: Response: Plan: Your signature and title Focus Note

40. © BRIDGEPOINT 2006 40 Contact Jan K. Kraus, M. Div –Manager, Spiritual Care Department Bridgepoint Health –CASC Specialist in Institutional Ministry –CASC Teaching Supervisor –416-461-8252 x 2172