11 Document one’s spiritual care accurately, cautiously, and usefully and in the appropriate records.
PPS 11 is about institutional documentation. It is asking how accuracy, caution, and usefulness have been a part of your documentation. It could be in the medical record, email notes to colleagues, progress logs, etc. Then you need to give the rationale for what you include or exclude. Cabot and Dicks wrote a book together nearly a century ago which describes the importance of note-taking for the chaplain. Their helpful reasons for note-writing include a check on one’s work, creation of ideas, release from strain, and a record better than memory.[1]
For more modern takes, Brent Peery explains a documentation method that many chaplain departments have emulated. He lists off the reason for visit, interventions, outcomes, assessment, and plan as the specific components.[2] Another part of this competency is addressing interdisciplinary communication in your charting. I had the pleasure of doing my CPE residency under Kevin Massey and was able to be introduced to a taxonomy that some of the local chaplains had researched and created. Their research showed the adoption of a normative language is a welcome development for chaplains working with other teams.[3]
[1] Richard Cabot and Russell Dicks, The Art of Ministering to the Sick (New York: MacMillan Company, 1957), 244-256.
[2] Simon Peng-Keller and David Neuhold, eds. Charting Spiritual Care: The Emerging Role of Chaplaincy Records in Global Health Care (Switzerland: Springer Publishing, 2020), 22-23.
[3] Kevin Massey et. al., What Do I Do? Developing A Taxonomy of Chaplaincy Activities and Interventions for Spiritual Care in Intensive Care Unit Palliative Care. BMC Palliative Care 14, (2015): 7.
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