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October 2016 Article of the Month
This month's feature is written by Gordon Hilsman,
ACPE/NACC Supervisor, Fircrest, WA;


Lee, B. M., Curlin, F. A. and Choi, P. J. "Documenting presence: a descriptive study of chaplain notes in the Intensive Care Unit." Palliative and Supportive Care 15, no. 2 (April 2016): 190-196

[Editor's Note (added 4/9/17): This article was originally featured before print publication.]


SUMMARY and COMMENT: This month's study reports on a retrospective review of chaplain chart notes in the ICU of one major teaching hospital, done from physicians' point of view. Two doctors and a medical student considered the free-text part of chaplain charting of 152 unique patients, amounting to 255 free-text-excerpts. They used standard methods for qualitative research, including pre-study close exploration of their own attitudes towards the subject, and an iterative process of highlighting words and phrases in the notes, identifying concepts and themes, using a resultant code book and quality analysis software to analyze the texts of the notes. They identified four themes that characterized the chaplain chart notes in that unit of that facility, and captured quotes from the notes that illustrated some of the most and the least useful from a medical staff point of view. No data were collected on the chaplains who wrote the notes.

The four themes identified and described were: 1) Frequent use of code language [p. 192] -- High use of "code words," generally not relevant to interdisciplinary staff and often repeated from the list of the interventions checklist part of the electronic medical record EMR). Phrases such as, "provided support for family and patient," "chaplain visited patient," and "chaplain provided compassionate presence" were common and seemed mostly to document that the chaplain was there. 2) Description rather than interpretation [pp. 192-193] -- Entries that contained what the chaplain observed without any reference to the care significance of the observation. For example, a note reader could see details of what was happening between family members in the room but could infer no indication of why it mattered to the family situation, either medically or personally. Repetition of clinical information easily found elsewhere in the chart was common. Examples such as "Patient has lung cancer and has been in hospice," and naming the medical diagnoses, were common. The study identified a few substantive notes that they found to be quite helpful as well. 3) Passive follow up plans [p. 193] -- Chaplains rarely mentioned previous spiritual care chart notes and their plans of care, and when they included them they were mostly passive, such as, "Informed family of the availability of chaplains," "Please page as needed," and "Encouraged family to contact chaplain if any needs arise." 4) Insight into relationship dynamics [p. 193] -- The chart theme most valuable to physicians, i.e., pointed help understanding ICU patient families, was spotty but sometimes seen as very helpful. The study identified a few notes that described family dynamics and information, but researchers were wary of the notes that seemed to take an advocacy role of patients over staff members.

The article acknowledges its limitation of being a one-hospital study from physicians' points of view, urging similar research to be done using perspectives of chaplains, nurses and social workers. It clearly confirms the potential value of chaplain perspectives in the medical record and calls for better representation of the depth of what chaplains actually do with and for patients and for richer portrayal of the patient needs they see from a broad spiritual perspective.

This is a fascinating small study that could be useful for improving chaplain charting in the medical record. While chaplain notes are not intended only for physicians, this study from a medical practitioners' perspective is invaluable as palliative care, hospice and ICU interdisciplinary teams generate greater interest in the actual experience of hospitalization from patients� and family�s own point of view. It could also prompt additional studies by pastoral care departments, like:

  • Who actually reads, seeks, and uses chaplain chart notes in your facility?
  • What are certified chaplains' attitudes and preferences regarding free text on the one hand and checkboxes on the other?
  • What effect do the categories of the EMR have in driving chaplains' thinking and caregiving function during a patient conversation?
The chaplain notes analyzed here bear signs of language left over from CPE verbatim writing that focuses on what the chaplain student does in order to explore and improve her care rather than about the patient and her attitudes about her condition, related life concerns, and family relationships. The result is that what these chaplains include in their notes tends to be quite chaplain-focused rather than patient-oriented. The check lists of chaplain interventions highlighted in EMRs are sometimes designed by accountants, managers, and administrators and thus do little to advance patient care. In the free text portion of the notes a similar character is followed, reducing language that helps interdisciplinary teams (IDTs) grasp the spiritual binds and struggles that are virtually always a part of hospitalization for serious conditions. This study can motivate the clinical ministry field, its practitioners, its students and its educators, to intentionally improve chaplain charting in the medical record for better inclusion as full members of IDTs.


Suggestions for Use of the Article for Student Discussion: 

Shining light on what CPE students write in the medical record in a consistent and substantive way seems to be essential for CPE programs, given the current movements in hospital care. Interdisciplinary teams (IDTs) need input from spiritual points of view and sometimes recognize that enough to yearn for them. Spiritual needs point to what is required to actually improve the "patient experience" and patient satisfaction scores. CPE programs that help students learn to write descriptively about people in pain do a great service in helping future chaplains to provide substantive and useful notes in the medical record.

This study offers considerable grist for CPE group discussions of the importance and difficulty of writing such notes and engaging in a career-long project of continually improving the art of capturing spiritual care work in the medical record. A few questions that can facilitate group discussions of this article can be:

  1. What is spiritual need in common terms that can be easily incorporated into the daily work of IDTs in the humanistic and pragmatic culture of health care?
  2. How do you see theological and medical perspectives differing and complementing each other? On whose turf are we practicing as spiritual caregivers in hospitals?
  3. How can the skills students learn for describing their CPE peers in written evaluations be translated into describing patient and families for use by IDTs?
  4. In all that a patient discloses to you, how can you keep one eye on what might be "clinically relevant" to IDTs?


Related Items of Interest:

I.  The following titles may be of special interest to chaplains:

Astrow, A. B., Wexler, A., Texeira, K., He, M. K. and Sulmasy, D. P. "Is failure to meet spiritual needs associated with cancer patients' perceptions of quality of care and their satisfaction with care?" Journal of Clinical Oncology 25, no. 36 (December 20, 2007): 5753-5757.

Cadge, W. "A profession in process." Chaplaincy Today 25, no. 2 (Autumn/Winter 2009): 26-27. [Available online]

Choi, P. J., Curlin, F. A. and Cox, C. E. "'The patient is dying, please call the chaplain': the activities of chaplains in one medical center's Intensive Care Units." Journal of Pain and Symptom Management 50, no. 4 (October 2015): 501-506.

de Vries, R., Berlinger, N. and Cadge, W. "Lost in translation: the chaplain's role in health care." Hastings Center Report 38, no. 6 (November-December 2008): 23-27.

Gibbons, J. L., Thomas, J., VandeCreek, L. and Jessen, A. K. "The value of hospital chaplains: patient perspectives." Journal of Pastoral Care 45, no. 2 (1991): 117-1125.

Handzo, G. "Spiritual care for palliative patients." Current Problems in Cancer 35, no. 6 (November-December 2011): 365-371.

Jensen, M. E. "Language and tools for professional accountability." Journal of Health Care Chaplaincy 12, nos. 1-2 (2002): 113-123.

McCord, G., Gilchrist, V. J., Grossman, S. D., King, B. D., McCormick, K. F., Oprandi, A. M., Schrop, S. L., Selius, B. A., Smucker, W. D., Weldy, D. L., Amorn, M., Carter, M. A., Deak, A. J., Hefzy, H. and Srivastava, M. "Discussing spirituality with patients: a rational and ethical approach." Annals of Family Medicine 2, no. 4 (July-August 2004): 356-361. [The September 2004 Article-of-the-Month.]

Puchalski, C. M. "The role of spirituality in health care." Baylor University Medical Center Proceedings 14, no. 4 (October 2001): 352-357.

Puchalski, C., Ferrell, B., Virani, R., Otis-Green, S., Baird, P., Bull, J., Chochinov, H., Handzo, G., Nelson-Becker, H., Prince-Paul, M., Pugliese, K. and Sulmasy, D. "Improving the quality of spiritual care as a dimension of palliative care: the report of the Consensus Conference." Journal of Palliative Medicine 12, no. 10 (October 2009): 885-904.

Ruff, R. A. "'Leaving footprints': the practice and benefits of hospital chaplains documenting pastoral care activity in patients' medical records.." Journal of Pastoral Care 50, no. 4 (1996): 383-391.

VandeCreek, L. and Burton, L. [for the Association of Professional Chaplains; Association for Clinical Pastoral Education; Canadian Association for Pastoral Practice and Education; National Association of Catholic Chaplains; National Association of Jewish Chaplains]. "A White Paper. Professional chaplaincy: its role and importance in healthcare." Journal of Pastoral Care 55, no. 1 (2001): 81-97.

Wagner, J. T. and Higdon, T. L. "Spiritual issues and bioethics in the intensive care unit: the role of the chaplain." Critical Care Clinics 12, no. 1 (January 1996): 15-27.

Williams, J. A., Meltzer, D., Arora, V., Chung, G. and Curlin, F. A. "Attention to inpatients' religious and spiritual concerns: predictors and association with patient satisfaction." Journal of General Internal Medicine 26, no. 11 (November 2011): 1265-1271.


II.  On the subject of chaplains' basic access to the Medical Record, see our November 2011 Article-of-the-Month.


III.  The following doctoral dissertation by Kevin E. Adams was completed under the direction of Diane Dodd-McCue, DBA Associate Professor, Department of Patient Counseling at Virginia Commonwealth University. It is available online from the university.

Adams, K. E. Patterns in Chaplain Documentation of Assessments and Interventions: A Descriptive Study. Dissertation. Virginia Commonwealth University, Richmond, VA, 2015. [(Abstract:) There is increasing emphasis on the importance of evidence-based care provided by all disciplines in healthcare. The Electronic Health Record (EHR) is becoming the standard for communicating assessments, plans of care, interventions, and outcomes of patient care. The spiritual care literature demonstrates the importance of assessing religious/spiritual needs and resources and developing plans of care to address the results of such assessment (Anandarajah & Hight, 2001; Borneman, Ferrell, & Puchalski, 2010; Fitchett, 1999; Fitchett & Risk, 2009; H. G. Koenig, 2007). This literature also suggests that addressing religious/spiritual needs of patients and families in the healthcare context can affect healthcare and adherence outcomes. The purpose of this study was to identify patterns of chaplain assessment and patterns of chaplain provision of services. This descriptive study was an exploratory retrospective analysis of categorical data recorded by clinical staff chaplains in the EHR at a single all pediatric healthcare institution, using contingency tables and frequency tables. The study examined chaplain use of assessment and service descriptors and the patterns of these descriptors when documenting chaplain visits. The results indicate chaplain preference for communicating in the EHR using general themes and concepts. This reveals an opportunity for chaplains to develop and implement a model of professional identity and articulation of care that is broad enough to accommodate the diversity of religion/spirituality chaplains encounter, yet able to articulate the specifics of patient and family religion/spirituality. The results found no consistent patterns among assessments or services provided. Further, the results found no indication of patterns between assessments made and the services provided. This presents an opportunity for chaplains to develop and implement a theory- driven, construct-based model of care that will connect the different facets of spiritual care. The assessments made will lead to plans of care that involve specific interventions resulting in appropriate outcomes related to overall patient and family care.]


IV.  [Editor's addition:] The writer of this Article-of-the-Month, Gordon Hilsman, DMin, has also written Spirituality in Common Terms, forthcoming in December 2016 from Jessica Kingsley Publications, London. Description [from the publisher's website]:

Encouraging a broad, compassionate, humanistic approach to spirituality, this book shows how patients' spiritual needs can be communicated well within interdisciplinary teams, leading to better patient wellbeing. This book describes the art of charting patients' spiritual perspectives in an open way that will help physicians and nurses to better direct medical care. It includes practical information on how to distil spiritual needs into pragmatic language, helping to demystify spiritual experience. Drawing on his extensive practical experience, the author also suggests key points to emphasize that will enrich chart notes for medical records, including brief, relative narratives, trusting one's own impressions, reflecting holistically on the patient's life, patient attitudes towards treatment and recovery, and describing families' opinions on the health care situation of their loved one. The book shows healthcare professionals of all disciplines how to engage in a shared responsibility for the spiritual care of their patients.



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