Chaplains and EMR Assessments: How to Use the NCP to Develop

Chaplains and EMR Assessments: How to Use the NCP to Develop Effective EMR Spiritual Assessment Documentation and Data Collection Benjamin D. Rose MDiv, BCC Alan B. Roof MDiv 2020 Peachtree Road, NW, Atlanta, GA 30309-1465 404-352-2020 shepherd.org

SHEPHERD.ORG WELCOME TO OUR JOURNEY 3/19/23 2

SHEPHERD.ORG Our Setting *All patients pictured have given written consent to Shepherd Center for use of their images.

SHEPHERD.ORG 152-bed hospital Annually we: treat more than 900 inpatients 575 day program patients more than 7,100 outpatients

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SHEPHERD.ORG Goals 1) Identify the spiritual concerns/needs and definition of spirituality created by the NCP and demonstrate the development of a Spiritual Assessment Flowsheet within an EMR using this terminology. 2) Discuss ways to alter this format and content based on the healthcare setting and EMR (examples from our setting will be provided). 3) Demonstrate the opportunities within this model for research using preset fields within the EMR to generate reports.

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SHEPHERD.ORG JACHO – Spiritual Support Offered CARF Requirement Met 3/19/23 8

SHEPHERD.ORG “This is all I have to do for documentation?” 3/19/23 9

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SHEPHERD.ORG Spiritual Diagnosis (Primary) Key Feature from History Existential Concerns Lack of Meaning Questions meaning about one’s own existence Concern about afterlife Questions the meaning of suffering Seeks spiritual assistance Abandonment by God or others Lack of love, loneliness Not being remembered No sense of relatedness Anger at God or others Displaces anger toward religious representatives or others Inability to forgive Concerns about relationship with deity Desires closeness to God, deepening relationship Puchalski, C. M., Ferrell, B., Virani, R., Otis-Green, S., Baird, P., & Bull, J., (2009). Improving the quality of spiritual care as a dimension of palliative care: Consensus conference report. Journal of Palliative Medicine, 12(10).

SHEPHERD.ORG Spiritual Diagnosis (Cont.) Key Feature from History Conflicted or challenged belief systems Verbalizes inner conflicts or questions about beliefs of faith Conflicts between religious beliefs and recommended treatments Questions moral or ethical implications of therapeutic regimen Expresses concern with life /death or belief system Despair/hopelessness Hopelessness about future health, life Despair as absolute hopelessness No hope for value in life Greif/loss The feeling and process associated with the loss of a person, health, relationship Guilt/Shame Feeling that one has done something wrong or evil Feeling that one is bad or evil Puchalski, C. M., Ferrell, B., Virani, R., Otis-Green, S., Baird, P., & Bull, J., (2009). Improving the quality of spiritual care as a dimension of palliative care: Consensus conference report. Journal of Palliative Medicine, 12(10).

SHEPHERD.ORG Spiritual Diagnosis (Cont.) Key Feature from History Reconciliation Need for forgiveness or reconciliation from self or others Isolation Separated from religious community or other community Religious specific Ritual needs Unable to perform usual religious practices Religious/spiritual struggle Loss of faith or meaning Religious or spiritual beliefs or community not helping with coping Puchalski, C. M., Ferrell, B., Virani, R., Otis-Green, S., Baird, P., & Bull, J., (2009). Improving the quality of spiritual care as a dimension of palliative care: Consensus conference report. Journal of Palliative Medicine, 12(10).

SHEPHERD.ORG Building Relationships are Vital 3/19/23 14

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GAINS FROM OUR FIRST SERIOUS EFFORTS - 3/19/23 Expanded EMR Footprint Refined use of NCP concepts Develop language Professionalized our work shepherd.org 19

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Design and Relationships 3/19/23 shepherd.org 22

CUSTOMIZATION BASED ON SETTING Concerns in our setting that differ from palliative care Other assessment models and documentation 3/19/23 shepherd.org 23

Standardize data collection Common language Format and use as other professions Quantitative Data Qualitative Data Imagine research and outcome data even if you can’t pull it or use it yet. You need data collection to play with data. 3/19/23 shepherd.org 24

Takeaways from Our Journey 3/19/23 shepherd.org 25