Documentation is often seen as the bane of Chaplains who work in clinical settings, especially hospitals and hospices. I know when I first started I had no idea what most of those medical signs and symbols meant. I still remember early on in my career putting my hand up to ask our reporting nurse what she meant when she said our patient had a “cabbage” (hint: it’s a CABG, or coronary artery bypass graft). While it can draw a chuckle at team it can also be very intimidating to wander from our world of Greek exegesis into a land of vague Latin contractions and abbreviations.

Our documentation, while not the best part of what we do, may be the only way that others see what we are doing and how it is helping. Therefore it is extremely important to do a good job with our documentation to make sure that it is clear, concise and relevant. It’s not an easy job, and one that we rarely get any consistent schooling in. It’s also the area that most of us get dinged on first when it comes to chart reviews and professional supervision. The Association of Professional Chaplains offers it’s own guidelines regarding standards regarding reporting and documenting care. The APC states that Chaplain documentation should include the following:

• Reason for encounter (i.e. request for total pain management, goals of care, compassionate extubation, centers for Medicare and Medicaid services, and Joint Commission requirements).
• Spiritual/religious preferences and desire for, or refusal of, ongoing chaplaincy care.
• Critical elements of spiritual/religious assessment.
• Patient/family-desired outcome with regard to care plan.
• Chaplain’s plan of care relevant to patient/family goals.
• Indication of referrals made by chaplain on behalf of patient/family.
• Relevant outcomes resulting from chaplain’s intervention.

While the what to include is more clear, exactly how to document this information is much more vague. In my time as a Chaplain I’ve seen documentation that has ranged from being a couple semi-intelligible half-sentences to English lit compositions. The first is unacceptable in that it leaves out so much necessary information as to be basically useless. The second is unnecessary and a poor use of time, including so many details that the important ones are lost.

The key is to document smarter, not longer, and you chart smarter by being focused on their Plan of Care. Including things like what they were wearing and the appearance of the room may help “paint the picture” but unless those details help support your care plan or their diagnosis they are unnecessary. To say that Mr. Jones wore brown slacks isn’t helpful, but to say that his slacks were ill fitting due to weight loss is.

In my own charting I try and follow a simple formula which is probably similar to what you would use back in journalism class in school:

• Who did you see (patient, family, staff)? Who did you talk to (include staff as this attests to cross-disciplinary support)?
• What do you see? How does the patient appear (tired, weak, pleasant, thin, pale)? Are there any visual as well as verbal indicators of pain?
• Why are you there? Is this a routine visit or an emergency? Is this an assessment? Were you consulted to visit for a reason? Is there a particular problem you are addressing?
• What did you do? What specifically clerical services did you provide? What else did you do that is related to their plan of care goals and interventions (taking them outside, providing life review, discussion of moral or ethical issues)?
• What do you plan to do next? Is a follow up call to family needed? Do goals or interventions on their Plan of Care need to be changed? Are other services or consultations needed?

Here are some more hints:

• Avoid over-using abbreviations, and consider getting rid of them altogether. They can be confusing or taken out of context (does OT mean occupational therapy or Old Testament?). Follow your agency’s guidelines and also consult a reputable source like Cahaba regarding medicare-approved abbreviations.
• Don’t try to diagnose psychological, emotional or physical ailments. Rather than say that your patient is depressed or anxious, say that they appear or express being depressed or anxious – trust me, there is a difference.
• Especially if you’re in hospice, know your patients’ diagnoses, know what to look for in terms of decline and document it. Often our tendency is to try to highlight the positives, but in hospice it’s best to highlight the negatives. Your documentation makes a difference and can help keep a patient on service.

Remember that your documentation is ultimately your best evidence of what you do and the value you add to your patients’ and families’ lives, as well as to the team. Don’t think that it’s not as important as anything else you do.