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…
- 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.
- 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.
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
- Spiritual concern(s)—Transfer VERBATIM from the General Tab in the Assessment
- Goals and Expected Outcomes—Transfer VERBATIM from the Care Plan Charting Tab
- Intervention(s)-Transfer VERBATIM from the Care Plan Charting TabResponse 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—