EVALUATING DOCUMENTATION - PowerPoint Presentation

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EVALUATING DOCUMENTATION

QUALITY

Carolanne

Hauck, MA, BCC

Director of Chaplaincy Care and Education, Lancaster General Health, Lancaster, PA

Beverly M Beltramo,

D.Min

, BCC

Director of Spiritual Support, Oakwood Healthcare System, Dearborn, MI

The EMR Team

Importance of Documentation

Working togetherStandard evaluation for quality even though we use different assessments. Is that possible?

Matrix

1 - incomplete

2 - thorough

3 – effective

Spiritual Assessment

Faith

Coping

Sources of Strength

Fears/Concern

Identified

Implications for Care

Relevance to Care Team

Follow-up

Narrative

Clarity

Brevity

Professionalism

Oakwood Healthcare

Spiritual Care

Assessment

Visit

with

:

*

Patient

declines

visit * Patient * Patient

& Family

* Family Only * Other

: ***

Reason

for Visit

:

* Initial Visit * Follow

up

Visit * Crisis/Urgent * Hospice/PRISM * Advanced

Directive

Assistance * Consult

from ***

ASSESSMENT

Patient’s Spiritual Issues

:

*

Despair/loss

of

hope * Forgiveness/seeking reconciliation * Grief

or loss (actual or anticipatory

) * Isolation/Alienation * Abandonment/disconnect

from

God * Lack

of social/family

support *

Loss

of

meaning/purpose * Advanced Directives *

* Addiction Issues * End

of

Life Support * Mental

Health

Issues * Spiritual Distress * Family Concerns * Acceptance *

* Unresolved Anger * Other

: ***

Patient’s

Sources of Strength/Support

*

Gratitude * Positive attitude * Wisdom * Peace * Hope * Acceptance * Sense

of

humor

* Strong

religious

faith * Family * Friends * Faith Community * Other

: ***

Distress/Suffering

: Patient’s REPORTED/ASSESSED level of suffering or distress:

1 - 10

Worries/Concerns/Fears

: ***

PLAN: SPIRITUAL INTERVENTIONS/RECOMMENDATIONS

* Active

listening/Supportive

dialogue * Educated

: Advance

Directives * Educated

: Bereavement Resources/grief process

* Educated

: Spiritual

Practices/resources * Explored beliefs/values/coping

* Explored

End of life

issues F * Facilitated

Family

Communication

* Facilitated

Expression of

Emotions * Facilitated

Life

Review * Provided

Prayer/Sacred Text /

Ritual * Provided

Relaxation

techniques

* Provided

Spread the Love Blanket

* Sacramental Anointing (Last Rites) * Sacrament

: Holy

Communion

* Supported

Expression of

grief

* Other

: ***

Interventions

Narrative: ***

OUTCOMES

* Acceptance expressed * Affect changed * Connection

with treatment team improved

* Increased coping * Cultural

Religious Needs

supported

* Expressed

Sense of

Meaning *

F

eelings

Expressed

* Gratitude Expressed * Grieving facilitated/expressed * Guilt/forgiveness addressed

* Hope identified/restored * No Change * Patient

declined further spiritual

support * Sense

of meaning expressed

ISSUES TO BE ADDRESSED IN A FUTURE ENCOUNTER

* Limited

Social/ Family

Support * Exploring Beliefs * Faith

Community

engagement * Faith

Community

Estrangement * Family/relationship needs * Financial/Social concerns * Forgiveness/Reconciliation * Guilt/Shame * Grief

and

loss * Ritual

or Sacramental

Needs * Spiritual/emotional distress * End

of Life

care * Extended

Length of

stay * Palliative

or Hospice patient

EXAMPLEVisit with: Patient Reason for Visit: Follow up Visit

ASSESSMENT Patient's Spiritual Issues

: Other: Patient sitting in chair but intubated and unable to talk. Patient communicated with facial expressions and her eyes and requested prayer

Patient's Sources of Strength/Support:

Other: Unable to discern

Distress/Suffering (

Patient assessed level of suffering/distress): 8 out of 10

Worries/Concerns/Fears

: Patient was alert and somewhat oriented. Patient nodded yes when I told her who I was. Patient again nodded yes when I asked if she'd like me to pray for her. No others were in the room.

PLAN: SPIRITUAL INTERVENTIONS/RECOMMENDATIONS

Current intervention

: Explored beliefs/values/coping, Provided Prayer/Sacred Text /Ritual and Supportive presence

Outcome

s: Gratitude Expressed via eye communication

Issues to be Addressed in a Future Encounter

: Extended Length of stay I will provide continuing pastoral interventions

.

Matrix

1 - incomplete

2 - thorough

3 – effective

Spiritual Assessment

Faith

Coping

Sources of Strength

Fears/Concerns Identified

Unable to assess very well

, given that patient was unable to speak, though she did communicate quite well non-verbally.

Implications for Care

Relevance to Care Team

Follow-up

Perhaps

can help team slow down and take time to allow her to communicate with them.

Narrative

Clarity

Brevity

Professionalism

Note well written. Perhaps more narrative?

Example #2Visit with: Patient & Family Reason for Visit:

Initial Visit ASSESSMENT

Patient's Spiritual Issues:

Other: Patient not responsive to my visit but son Larry was bedside. He said the patient was Assembly of God Christian.

Patient's Sources of Strength/Support:

(Per son) Strong

religious

faith ,

Family, Friends and Faith Community

Distress/Suffering (Patient assessed level of suffering/distress):

6 out of 10

Worries/Concerns/Fears

: Son is of opinion that patient is waking up.

Hopeful for a full recovery for his dad. Son

said Patient's church is

_______Assembly

of God. Son said he'd contact patient's pastor for a visit. Son also a member there.

PLAN: SPIRITUAL INTERVENTIONS/RECOMMENDATIONS

Current intervention:

Active listening/Supportive dialogue, Explored beliefs/values/coping and Provided Prayer/Sacred Text

read.

Outcomes

: Gratitude

Expressed.

Son was complimentary of the excellent care being provided by the hospital and medical staff. Son expects patient to awaken and leave the hospital soon. Patient does need to talk to the doctor about the new diagnosis of heart attack he has heard.

Issues to be Addressed in a Future Encounter:

Exploring

Beliefs and possible “new normal.”

Matrix

1 - incomplete

2 - thorough

3 – effective

Spiritual Assessment

Faith

Coping

Sources of Strength

Fears/Concerns Identified

Perhaps focused too much on faith?

Solid conversation about strengths

and faith

Implications for Care

Relevance to Care Team

Follow-up

Will help staff to know son’s expectations, also will help to know patient has strong religious belief. They will appreciate son’s positive feedback.

Narrative

Clarity

Brevity

Professionalism

Clear language,

written well.

Lancaster General Health Chaplaincy

Care Note :

How did you select this

pt

? i.e. consult from [name], [title]; self-initiated based on…;

pt

requested visit; etc

.

Assessment

: identify

the spiritual risks, concerns, or struggles as well as the spiritual resources that the patient and/or family bring to this current hospitalization. Consider these areas: life review, hopes, values, fear, meaning purpose, beliefs about afterlife, spiritual or religious practices, and cultural norms, beliefs that influence understanding of illness, loss history, coping, guilt, forgiveness, and life completion tasks

.

Goals

for Spiritual

Care

:

Given

the above assessment, what are the goals for the patient or family during this hospitalization?

Interventions

:

How did you work towards these Goals during the visit

?

Outcomes

:

What were the results of your visit? How did patient or family respond? Describe behavioral changes to that indicate response. Was there progress toward the goals? Is there more work to be done toward the goals? If so, how will that be done? Follow-up needed?

Example 1 LGHAssessment:  Patient is grieving mastectomy and now the impending loss of fertility and her child-rearing days. History of childhood abuse is contributing to confusing feelings about changes in body image and sexual intimacy. Faith is very important aspect of spiritual life. Pt is seeking Catholic perspective on moral / ethical dimensions of hysterectomy prior to making

decision. Patient’s husband is very supportive.

Matrix

1 - incomplete

2 - thorough

3 – effective

Spiritual Assessment

Faith

Coping

Sources of Strength

Fears/Concerns Identified

Catholic

Actively grieving

Faith,

spouse

Ethical aspects, sexual intimacy, past hx of abuse

Implications for Care

Relevance to Care Team

Follow-up

Follow-up not noted

Good for team

to know spiritual and emotional side

Narrative

Clarity

Brevity

Professionalism

Succinct clear and to the point

Test Pilot Feedback

Positives

Method for evaluation

Most evaluations matched on 4 samples

Sparked some good discussion

Good tool to help students learn to chart

Negatives

As is: only good for Assessment

Did not like

thorough

prefer

adequate

Would like a description of “effective” and “thorough”

Not entirely clear how to use—several different interpretations

Next Steps