The Documentation Template We Use at Cornerstone Hospice

The Documentation Template is a guide that I developed for Chaplains to present their patient in a very professional manner.  Please review it as I have included instructions along the way.  Yes, we have a piece called the Big MAC.  The Big MAC documents the Chaplain's observations of decline.  These observations are crucial to highlight that the patient is not getting better, but is, indeed, in a state of decline.  I am happy to answer your questions about this template.  I can assure you it accomplishes much.  One of Team Managers stated that when she wants to know what is happening with a patient she goes to the Chaplain's Clinical Note.  Here it is:

Template for Spiritual Care Documentation

Patient information—Pt. presented as a 78 year old, Euro-American male, diagnosed with Alzheimer's Disease, was found in his room seated in his wheelchair.

Purpose of the visit—Not about the task of visiting to keep up with POC, but to deepen the spiritual care relationship…

Observations

1. Pain level/scale:  VAS-is only for those lucid     PainAD-ONLY for dementia patients   FLACC-ONLY for those who cannot respond because of being in a deep sleep or for some reason cannot speak. This is NOT for dementia patients.   This is not an essay question.  Simply write: 0-10, 1-10, 2-10, etc. and name the scale.
2. Safety issues:  You may write this as simple as: No safety issues observed; or, you can state what the safety issues are and how you addressed this with the patient.

Decline

                Mobility-State HOW the patient ambulates if at all

                ADL’s-State as much about the ADL’s as possible: Pt only eating half of her meals/ pt requests assistance with bathing/ pt now taking long naps during the day/

                Communication-HOW is pt speaking? With exertion, not making sense, etc.

Plan of Care

1. Spiritual concern(s)—Transfer VERBATIM from the General Tab in the Assessment
2. Goals and Expected Outcomes—Transfer VERBATIM from the Care Plan Charting Tab
3. Intervention(s)-Transfer VERBATIM                from the Care Plan Charting Tab
   Response of the patient/family—Use the verbiage from the Users’ Guide where possible            Collaboration—Use the following language: Chaplain collaborated with ______________ about the patient.                                                                                                                                                                      Subsequent visit—