Research

Initial Chaplain Visit Assessment and Documentation Examples

Saul Ebema, DMin

Initial Chaplain Visit Documentation

The hospice Chaplain must complete the initial assessment visit no later than 5 calendar days after the patient has been admitted to hospice care.

This initial assessment must identify the psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient‘s well-being, comfort, and dignity throughout the dying process.

As you may already know, I like the DAROP format. This format stands for five sections that comprise this narrative framework:

  1. Data
  2. Action
  3. Results
  4. Observations
  5. Plan

EXAMPLE ONE

Here is an illustrative example based an 89 year old male with a diagnosis of Alzheimer’s in a Skilled Nursing Facility.

DATA: Patient was identified by facility staff and room number. The plan of care for this visit is Initial spiritual assessment. Patient is an 89-year-old male with a diagnosis of Alzheimer’s. Chaplain encountered patient in his room where he was up in his wheel chair awake and denied pain. Chaplain engaged patient in conversation to help promote self-expression. He seemed confused and forgetful (this is in relation to his diagnosis). Chaplain phoned patient’s daughter Alicia for further assessment and support. Chaplain explored her feelings regarding the patient’s declining health. She said she was coping better at this point and denied any needs. She however stated that patient is very spiritual and used to be a deacon in his Baptist church. She said that patient finds encouragement in faith expressions like scripture and prayer.

ACTION: Chaplain validated her feelings and encouraged her to call hospice as needed for further support of which she was appreciative. Because patient was in his room alone, chaplain offered supportive presence to help counter his sense of social isolation and spiritual comfort through scripture and prayer to help sustain his sense of relationship with God.

RESULTS: He seemed to enjoy the attention he got from the one on one visit. His mood changed, he was happy and appeared comforted by prayers and scripture reading as evidenced by his calm appearance.

OBSERVATIONS: Although patient was pleasant during visit, he was very confused and unable to hold a conversational line of thought.

PLAN: Chaplain will visit patient twice a month for supportive presence and spiritual support. The visit frequency will increase as needed.

EXAMPLE TWO

Here is an illustrative example based a NON VERBAL 80 year old male with a diagnosis of COPD. Pt is at home with his wife.

DATA: Chaplain met patient at home with his wife (in a home visit, patient identification seems obvious). The plan of care for this visit is initial spiritual assessment. Patient is a 80 year old male with a diagnosis of COPD. Patient was sitting up in his bed, awake and remained nonverbal. Chaplain observed for hints of discomfort in the patient and saw no facial gestures or body movements indicating distress, instead he seemed peaceful (even when the patient is nonverbal or unresponsive, pain has to be assessed). Chaplain provided emotional support to the wife who seemed overwhelmed with the burdens of the patients care and declining health needs. In her own words, “I feel like I can’t do this alone anymore; none of my children come to help.” She continued to speak about the patient’s health and faith histories. According to the wife, both her and the patient are devote catholic and find a lot of strength from their faith as a coping mechanism.

ACTION: Chaplain legitimized and normalized her feelings to help reduce anxiety. Chaplain helped her realize that crying or being upset are normal reactions that need to be expressed. Chaplain explored with her new ways of coping. Chaplain also updated Hospice Social worker Mary Holmes for further support for the wife in terms of respite care, caregiver or other available resources. The social worker agreed to follow up. Chaplain then moved with her next to the patient and prayed for both to help offer a sense of God’s attentiveness to their situation and reduce anxiety.

RESULTS: The wife was very appreciative of visit and verbalized feeling much better after talking with chaplain. The patient remained peaceful after the prayer.

OBSERVATION: Pt seemed weak and continues to decline. The wife was struggling with caregiver stress and the burden of care.

PLAN: Chaplain will visit three times a month to offer emotional and spiritual support to the wife and patient.

EXAMPLE THREE

This example is based on an 84 year old female with a diagnosis of unspecified severe protein-calorie malnutrition. Patient resides in a nursing home. She has no children and a distant relative is her Power of attorney for healthcare. (Your documentation should also be tied to the diagnosis that’s why it is important to know the symptoms of the patient’s hospice diagnosis.)

DATA: Patient is an 84 year old female with a diagnosis of unspecified severe protein-calorie malnutrition. Patient was identified by facility staff and name. The plan of care for this visit is initial spiritual assessment. Chaplain encountered patient in her room where she was up in her wheel chair next to her bed. She denied pain. She verbalized having a lack of appetite and no desire to socialize with other residents by the common area who were playing bingo.

ACTION: Chaplain engaged patient in life review to help foster a sense of hope, and meaning. Patient enjoyed talking about her childhood in Chicago, with laughter she spoke about her parents and important lessons they taught her. She spoke about her late husband and their passions for gambling and travel. She also spoke about her career as a nurse at the local hospital which she found fulfilling. Towards the end, she said, “recalling these memories make me realize that I have lived a good life.” Chaplain affirmed her feelings and offered spiritual comfort consistent with her Baptist faith tradition through scripture and prayer. Chaplain also called her Power of attorney for healthcare and left a message. Awaiting return call. Care coordinated with facility RN Julie who said that patient continues to lose weight due to lack of appetite.

RESULTS: After chaplain engaged the patient in life review, she had a strong feeling of gratitude and peace. It made her realize that she had a great life. She was also appreciative of the prayer. In her own words, “I love to pray and used to be one of the prayer warriors at my church.

OBSERVATION: Pt seemed weak and is losing weight due to her lack of appetite and somewhat withdrawn from the other residents. She however enjoyed the one on one time with the chaplain..

PLAN OF CARE: Chaplain will continue to visit patient twice a month with an occasional PRN and needed.

EXAMPLE FOUR

Illustrative example based on a 68-year-old female patient with a hospice diagnosis of congestive heart failure in a skilled nursing facility. .

Data: Patient was identified by facility staff and name. The plan of care for this visit is Initial spiritual assessment. Patient is a 68-year-old female with a hospice diagnosis of congestive heart failure. Chaplain encountered patient by the dining room where she was up in his wheel chair, leaning to her left side with support pillows as the facility aide was completing feeding her lunch. Patient was coughing after eating and stared into space.

Action: Chaplain greeted patient, held her hand, encouraged eye contact and attempted to engaged her in conversation to help promote self expression. Although her verbal responses were minimal, she seemed confused. Chaplain read scriptures and prayed with patient.

Results: When chaplain brought up husband’s name, patient began to talk about him as if he were still alive, although he has been deceased for years. Patient appeared comforted by prayers and scripture reading as evidenced by calm affect and closed eyes.

Observations: Patient coughed after mealtime, leaned to side, and was unable to engage in reality-based conversation.

Plan: Chaplain will visit patient twice a month to provide supportive presence and spiritual support.

Everyone knows that the task of being a Hospice chaplain is harder than any field in professional chaplaincy. Our goal is to train chaplains and prepare them for competent service within the Hospice industry.

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