5 Keys to Excellence in Documentation

I can remember the days when I first started in hospice chaplaincy. No one taught me how to document my visit. While we used the FAIERS note, I didn’t know what was expected. In Toward Excellence In Spiritual Care, the Chaplain handbook I wrote for our hospice, I left nothing to chance. In the current Medicare environment every discipline must write a Clinical Note that defines the visit. The Note must paint the picture and explain what happened in the visit. There are 5 Critical Keys to Excellence in documentation: 1. Document pain. What did you observe about the patient and pain? What did the patient say her pain level was? Be sure to document the number out of 10 on the VAS scale. If the patient is not a dementia patient but is non-verbal use the FLACC scale. If the patient is a dementia patient, use the PainAD. 2. Document decline. Be sure to use “The Big MAC”. If you don’t know what that is, please see previous postings as it is fully explained. If you still need assistance please use the Comment section or for further consultation please contact me at rbehers@hotmail.com. 3. Document collaboration. Collaborating with the patient’s caregiver, facility staff member, hospice nurse or other discipline, becomes part of the record. One thing a minister/Chaplain will struggle with if he or she came into hospice from the pastorate is documenting collaboration. Pastors can be lone rangers and not collaborate as the Pastor/leader. In hospice care, the team concept is the philosophy. 4. Document the patient’s or caregiver’s response to visit. This piece memorializes the visit and can be used as part of your understanding of the patient’s spiritual or existential pain. After several visits you may notice a pattern that will greatly assist you in providing proper care. 5. Document your subsequent visit time frame. It is best to set a time frame with the patient or caregiver at the close of the visit. Remind them that you will call to confirm the next visit with them. Being forward looking provides hope for the patient and reassurance for the caregiver. One thing never to do is to forget a visit. Call if you will be late, but never forget a visit. Use your Scheduler as your daily guide to who you visit. These keys will hold you in good stead with the patient and family. Bless you, Chaplain Friends, for your hard work.