Two Charting Practices Chaplains Should Change

Abstract

Hospital chaplains routinely document the spiritual care they provide in patients’ medical records, which is a useful and important practice. This article advocates two charting practices chaplains should change to better align our documentation with the beliefs and values of our profession.

If somebody forgets (my name), I feel that it's I who am forgotten.

—Frederick Buechner

Remember my name and you add to my feeling of importance.

Dale Carnegie

Writing in the first person automatically gives you a point of view.

Truman Capote

When I began my chaplaincy career over three decades ago, hospital chaplains didn’t always chart (i.e., write notes in patients’ medical records documenting their visits). Some chaplains and spiritual care departments chose not to chart, believing it wasn’t part of their job, while others wanted to chart but were denied access to medical records by their organization. It was difficult in those days to find recommendations and best practices for charting in the chaplaincy literature, enough so that I wrote an article on the subject. ¹

Thankfully things have changed so now it is generally a given that chaplains write chart notes. ² That is a good thing for several reasons:

Charting conforms our practice to the standard of all other disciplines involved in patient care who follow the hospital maxim, “If it isn’t charted, it didn’t happen.”

Writing chart notes allows chaplains to offer other caregivers involved in a patient's case insight into and an assessment of the spiritual aspect of the patient, our area of expertise. This promotes and demonstrates the spiritual aspect of holistic care, a cornerstone of the bio-psycho-social-spiritual model of healthcare. ³

And charting helps raise awareness of who chaplains are and what we do among those who read the medical record. Very few of our medical colleagues ever see us in action with a patient or family but in my experience, many of them read our notes in the chart and through them learn about chaplaincy and our impact on those we serve. ⁴

So charting is an important and useful practice for chaplains and is part of our job. But there are two charting practices frequently employed by chaplains I argue should be changed.

Name Not “Patient”

The first is the practice of referring to patients in our chart notes as “patient” or “pt” rather than by their name. For example: “I responded to a request from the patient for spiritual support.” This is a common practice in charting for some disciplines, designed to focus documentation on the patient who is receiving care. It's a practice that grows out of a desire for objectivity and clinical detachment. The abbreviation “pt” began as a time saver in the days of paper charts and handwritten chart notes. Chaplains follow this practice, I expect, because we see other disciplines using it and assume it's the proper and only charting style.

But charting in this fashion doesn’t reflect our beliefs and values as professional chaplains. ⁵ Chaplains are among those who champion the humanity of our patients, recognizing each as a unique person, with a name, a family, and a story, and not as a medical record number, diagnosis, or case, as they are so often, sadly, reduced to in the medical system. Why then do we opt for referring to those we serve in our charting as “patient,” their role in the hospital/medical system, rather than by their name? The word “patient” comes from an Old French word meaning “one who suffers.” I worry we add to patients’ suffering by failing to call them by name in our charting.

Early in my career, I co-led a grief support group on a mental health unit with Karl, a mental health associate (i.e., nursing assistant). Karl had a PhD in English, was an accomplished poet, practiced Buddhism, and was one of the kindest people I’ve ever known. In his charting, Karl always referred to his patients as Mr. Smith or Ms. Doe. He may have been the only caregiver on the mental health units who charted this way and he did so to accord dignity and respect to those he served, many of whom were offered little dignity or respect in society due to their chronic and persistent mental illness. I saw in Karl's charting the same kindness and compassion that were the hallmark of the care he provided. I learned from Karl you can use a person's name in charting and that doing so helps enhance their dignity, which is valuable in light of the many ways the healthcare system erodes dignity.

As some have observed, there are many similarities between the experience of being admitted to a hospital and of being sentenced to prison:

You are given a number.

Your street clothes are replaced by institutional garb.

You are told what and when you can eat.

The institution determines if, when, and how many of your loved ones can visit.

And you are typically required/asked to remain in the institution until it is determined you are free to leave.

Hospitals treat people this way, ostensibly, for their own good. But there are times when patients feel as if aspects of their humanity have been forgotten or get lost in how the medical system treats them. It is not uncommon for people in the hospital to feel as if they are simply another medical record number, another case, another diagnosis, or just another patient. Chaplains shouldn’t contribute to this feeling in those we serve.

So, to help preserve our patients’ humanity and enhance their dignity, I recommend chaplains refer to them by their name in our charting, not as “patient” or “pt.” We should use the name preferred by the patient, the name we use in speaking to them, deferring to a formal version whenever possible and appropriate—for example, Mr. Smith or Ms. Hernandez. We should also use the patient's preferred pronouns in our charting as another way to personalize our care and honor those we serve. Chart notes have a different tone, warmer and more human when the patient's name is used rather than the generic “patient” or “pt,” as in the following before/after example:

Chaplain met with pt as pt had requested spiritual support. Pt was engaging and reflective. Pt shared her fears and concerns as she approaches end of life. Pt verbalized faith in God and said it brings her peace. Pt shared stories of her family and of how their support has sustained her. Chaplain assisted pt in exploring her thoughts and feelings and provided calming presence, empathy and listening.

I met with Ms. Doe as she’d requested spiritual support. Ms. Doe was engaging and reflective. She shared her fears and concerns as she approaches end of life. She verbalized faith in God and said it brings her peace. She shared stories of her family and of how their support has sustained her. I assisted Ms. Doe in exploring her thoughts and feelings and provided calming presence, empathy and listening.

Referring to a person as “patient” in charting is a form of forgetting their name. In doing so, chaplains run the risk, according to the Frederick Buechner quote above, of forgetting the person or an important aspect of their humanity. By using their name in our charting, we are remembering the person and, according to the quote above from Dale Carnegie, adding to the importance of their humanity and personhood. This is even more vital since patients and family members have access to their medical records via OpenNotes allowing them to read what we write. ⁶

First Person Not Third

The second practice I argue we should change is charting in the first rather than the third person. Writing in the third person involves referring to yourself in chart notes as “chaplain” or “this chaplain,” for example, “Chaplain responded to a request from Mr. Doe for spiritual support.” My sense is chaplains adopted this practice from disciplines like nursing and social work, who often chart this way. Charting in the third person is done in the hopes of offering an objective, concise summary of events. It is intended to take the writer out of the picture and place the focus entirely on the patient. To me though the third person format, especially as employed by chaplains, is cumbersome, wordy, and calls more attention to the writer rather than less. Consider this example:

Chaplain initiated visit to introduce self, spiritual care services and assess needs. Chaplain arrived to find that patient had just been intubated and so was unable to participate in a visit with the Chaplain at this time. There was no family present at this time so Chaplain will attempt to follow up with patient and family at a later time if possible.

In this note, “chaplain” is mentioned four times and the patient—the focus of the intended visit—isn’t mentioned by name at all. “Chaplain” then becomes the focus of the note and the patient fades into the background. It seems far better to focus on the patient, by name as I argue above, and refer to ourselves in the first person, which is more natural and straightforward.

A better version of the note would be:

I stopped by to offer spiritual support to Ms. Gonzalez but found that she had just been intubated. There were no family members or visitors present. I will attempt to follow up with Ms. Gonzalez and family another time.

Writing in the first person sounds more natural than the third person and so is clearer and more understandable to the reader. Writing in a clear and understandable style helps make our chart notes worth reading for other disciplines. ⁷

As a profession, chaplains don’t strive for the kind of clinical objectivity and professional distance employed by other disciplines. We resonate with the wisdom of Naomi Remen, who wrote, “We cannot serve at a distance. We can only serve that to which we are profoundly connected, that which we are willing to touch.” ⁸ Writing in the first rather than the third person better reflects our willingness to connect with and touch those we serve. It also reflects the fact we are present in the patient encounter, a part of the story of the visit we are documenting.

We do well to always include a spiritual assessment in our charting as that is our area of expertise. Offering an assessment is another reason our chart notes are worth reading for other disciplines. Charting in the first person, according to the Truman Capote quote above, provides us with a point of view for our assessment.

So I commend these two charting practices to you—using the patient's name and charting in the first person. These may seem like small, even insignificant, matters of style, unimportant to the spiritual care we deliver. But in fact, the style of these practices embodies the substance of our work in important ways. They more accurately reflect our beliefs and values as professional chaplains. They honor the humanity and the unique spirits of those we serve. And they allow us to clearly offer our unique perspective as spiritual caregivers to others who read the chart.