Friday, August 1, 2014

SPECIAL Clinical Post: Pain and Decline

Chaplains and Their Clinical “Observations” Chaplains are not licensed to assess; therefore, they observe and document using the term “observed”. There are two critical areas that a Chaplain must excel in when it comes to making these clinical observations: Pain and Decline. It has been stated by various leaders in hospice that a Chaplain’s documentation has saved that particular hospice money when charts were reviewed by Palmetto or other Medicare intermediary. The latest requirement of Chaplains is to state which pain scale they used: VAS scale, FLACC scale, or PainAD. Pain Scales The VAS or Visual Analogue Scale is a simple 0-10 scale highlighted by ‘smiley faces’ and ‘sad faces’ for the adult patient. The FLACC or Face, Leg, Activity, Cry, Consolability Scale is a broad-based scale used to observe pain levels in infants and children up to 7 years of age and for adults that are non-communicative (but not dementia patients). It bases its scoring upon 5 areas of observation as posited in its title. Based on the scoring, a Chaplain can document a pain level. The PainAD or Pain Assessment in Advanced Dementia is used to observe and document pain levels in dementia patients. The Chaplain must document using the verbiage similar to this: “Patient states her pain is 3/10 on the VAS Scale.” Observations of Decline The Clinical Chaplain observes indications of decline and documents these observations so that the patient’s chart will reveal a history of decline. The means that I instruct our Chaplains to use is called The Big MAC. The title is easy to remember and easy to teach as most Westerners remember the McDonald’s commercial about The Big Mac. With so much information to be included in the Chaplain documentation, it helps for a Chaplain to have a simple reminder that decline must be documented. The Big MAC includes the following: M—Mobility: How does the patient ambulate? Wheelchair, walker, cane, holding onto the wall, needs assistance? When documenting your observations of decline, note any difference in the manner the patient ambulates from your prior visit. A—Activities of Daily Living: The patient and/or family member(s) may assist you with this observation. Areas of ADL’s to observe or gain information regarding include: eating, sleeping, bathing, incontinence, transferring, toileting. Helpful questions include: How much is patient eating? What amount compared to last visit? Has food been pureed? How is appetite? How is patient sleeping? All night? Partial night? Napping for long stretches during the day? Up at night, sleeping during the day? How many hours of sleep, day or night? Is patient bathing him/herself? Assistance needed? If so, contact Nurse to meet this need. C—Communication: Is there any difference in the manner in which the patient speaks? Is the patient short of breath compared to your last visit? Is the patient struggling to remember words, gets mixed up, repeats the same phrase, has troubled making sense? (all compared to your last visit with patient) Since both of these matters of documentation are proprietary to Cornerstone Hospice and Palliative Care, Inc. I request that my colleagues in leadership positions in spiritual care in other hospices please seek permission before adopting these in your hospice. Please contact me through this blog site and we will assist you. Thank you.

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