Wednesday, September 10, 2014

It’s the little things that can make a big difference.

This quote is attributed to the late John Wooden, “It's the little details that are vital. Little things make big things happen.” That is never more true than in a hospice Chaplain’s documentation. I can’t stress it enough the imperative that every Chaplain include in his or her Clinical Note a pain score based upon an applicable pain scale and a statement of decline. We are in a day when Medicare is scrutinizing hospice closely. As a member of the IDT, the Chaplain is looked upon to hold her end of the load. Clinical excellence is expected. What is your process for writing a Clinical Note? I am providing a checklist of sorts to remind you what should be included in every Clinical Note: Chaplain Clinical Note 1. Description of the patient: 2. Spiritual pain issues raised by patient: 3. Interventions Chaplain used to address spiritual pain: 4. Pain observations: What number? What scale? 5. Safety issues observed: 6. Patient’s response to the visit: 7. Collaboration: 8. Observations of decline: Big MAC observations 9. Subsequent visit: 10. Signature: This seems to be a cause for heartburn for some Chaplains because the Note is electronically signed. However, it is always appropriate and important for the Chaplain doing the Note to sign it. The details of your work can and do make a big difference. Thank you for your compassionate ministry to your patients. You do make a difference. Bless you, Chaplains, for who you are and what you do.

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