Chaplaincy Services Editing and Proofreading Services

Spiritual assessment is a document expected in more places than its contents are specified. Guidance published for the Joint Commission's hospital program says it is important to evaluate spiritual needs, beliefs, values, and preferences for two groups of patients.¹ They are patients receiving psychosocial services to treat alcoholism or other substance use disorders, and patients receiving end-of-life care.¹ It adds that each organization would determine how these needs will be identified, since the standards do not define such elements.¹ Example questions follow, labeled as examples to consider rather than prescriptive requirements.¹

Three authorities, three different variables fixed

The regulation of what a chaplain writes is divided, and each body fixes a different part of the problem. Hospice conditions of participation set the record and the schedule. Veterans Health Administration policy sets who writes and when. Navy policy sets how a note is marked, stored, and destroyed. Federal corrections regulation reverses direction, requiring the written statement from the inmate rather than the chaplain.² A department writing its own documentation policy is reconciling instruments never drafted to sit together.

What hospice regulation fixes

A hospice interdisciplinary group must include individuals qualified in four professional roles, and the fourth is a pastoral or other counselor.³ The group reviews, revises, and documents the plan of care no less frequently than every 15 calendar days.³ The comprehensive assessment is completed no later than five calendar days after the election of hospice care.⁴ An initial bereavement assessment covers social, spiritual, and cultural factors affecting the ability of the family and others to cope.⁴

Core services carry four short subparagraphs on spiritual care. The hospice assesses the patient's and family's spiritual needs, and provides counseling to meet them in accordance with the family's acceptance of the service and in a manner consistent with their beliefs and desires.⁵ It makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support those needs, and it advises the patient and family that the service exists.⁵

What the note becomes once it is filed

A chaplain's entry in a hospice record is a clinical record entry, governed like every other one. The clinical record includes the plan of care and its updates, the assessments, clinical notes, and a good deal besides.⁶ All entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice.⁶ Records are retained for six years after the death or discharge of the patient, unless state law requires longer.⁶ Five adjectives govern that requirement, and each describes the document rather than the encounter it records.

One data element that goes only to clergy

The federal privacy rule permits a facility directory holding a patient's name, location in the facility, condition described in general terms, and religious affiliation.⁷ Directory information may go to members of the clergy, and to other people who ask for the patient by name, except that religious affiliation goes to clergy alone.⁷ The rule ordinarily requires that the individual be given an opportunity to object. Where that opportunity cannot practicably be provided because of incapacity or an emergency treatment circumstance, the provider may still use or disclose directory information.⁷ An orientation handbook compressing all of that into one line will lose either the clergy exception or the emergency provision, and a volunteer at a front desk has nothing else to work from.

What Navy policy fixes instead

Chaplain notes on confidential communications are marked as Confidential or Privileged Communication and kept apart in the chaplain's personal files from professional and sensitive information.⁸ Protected information is secured against inadvertent disclosure, and where it is stored digitally the chaplain takes steps to ensure the privilege cannot be breached.⁸ Chaplains ensure destruction through a secure means when the records are no longer needed, and religious program specialists and chaplain assistants will not keep notes on any confidential communications.⁸

Those provisions govern marking, storage, and disposal rather than substance. The instruction reaches content once, requiring that identities be thoroughly protected when current or former counselees are referenced in consultation, supervision, or education.⁸

What Veterans Health Administration policy fixes

Where a more in-depth spiritual assessment is indicated, a chaplain is the only subject matter expert authorized to conduct it and to devise a spiritual care plan.⁹ Documentation of spiritual assessments is required within stated periods that vary by setting. It is within the first 24 hours in intensive care and hospice, and within 72 hours in acute inpatient mental health.⁹ It is within seven days in residential substance abuse treatment, and within 14 days in Community Living Centers, spinal cord injury, and polytrauma.⁹ Four deadlines govern a document whose contents that directive does not prescribe.

The record we never see, and the forms we do

A patient's clinical record is not a document to send to an outside editor, and we do not ask for one. We make no theological, pastoral, or clinical judgment. What reaches us is the other kind of document: policies, assessment forms, orientation handbooks, competency descriptions, and published reflection. We check that a term defined in a policy is used that way in the training built from it. We check that a period stated in one paragraph is the period stated in another, and that a form's questions can be answered by the person who will be holding it. Client material is treated as confidential without exception.

A department writing its own assessment form does what the authorities above it declined to do. The form is used by people who never read the regulations behind it, and its questions are the only part of that structure most of them will see.