Clinical Practice

Hospice Documentation: By Rodney Bolejack, D.Min.

General Guidelines for documentation

  • What are the pt’s issues related to life, illness, death and dying?
  • What needs or concerns were expressed or observed
  • Recording unique cultural or religious preferences

Record the story that tells;

  • Who is the pt or family
  • Significant relationships and dynamics
  • Coping styles
  • Spiritual perspectives
  • View of afterlife/ death
  • What the pt or family want

Observation:

Identify the (spiritual) issues of concern: Describe the need and Illustrate using quotes from the patient or family

Explain the need or concern using spiritual language whenever possible

EXAMPLE: Existential aloneness

Intervention:

Document the intentional ministry: Describe the purpose of the interventions. May be what the chaplain did or will do.

Example: “Pastoral dialogue provided for reflection on fears associated with the afterlife.”

Example: “Patient experiences increased awareness of God’s presence during communion. Chaplain will provide communion with family present 2x/mo.”

Outcome:

Document the observed or reported results of interventions:

“Patient reports communion as meaningful and increases inner peace.”

“Patient seems less anxious partly as consequence to experiencing forgiveness.”

SPIRITUAL ISSUES

Providence

Faith

Hope/Future-Story

Community

Reconciliation

Meaning/Purpose

Guilt/Regrets

Anger

Trust

Existential aloneness

Peace

After-life

Letting Go of the

Finite World

Legacy

Intervention:

Chaplain provided/will provide:

Pastoral dialogue

Reflective conversation

Spiritual Reflection

Faith Expressions

Conducted Ritual

Provided Blessing

Ministry of Presence

Prayed for _____

Read Scriptures for_____

Educated about ___

Projected imagery of afterlife

Purpose of intervention

  • To allow the pt to reflect on Life story
  • To sustain or affirm faith
  • To create awareness of
  • To increase sense of peace
  • To transform hope
  • To explore faith realities
  • To create meaning
  • For discovery of the scared in daily experiences

Pt Outcome of Intervention

  • Expressed assurance
  • Seemed less anxious
  • Reports increased inner peace
  • Feelings were validated
  • Greater sense of peace
  • Requested further dialogue

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