In the ever-evolving landscape of healthcare, the role of healthcare chaplains has expanded, particularly with the rise of electronic medical records (EMR) and the introduction of the 21st Century CURES Act, which includes the "Open Notes" initiative. This legislation has significantly impacted how medical professionals, including chaplains, document their interactions with patients, as it allows patients direct access to their medical notes through patient portals. Understanding this shift is crucial for healthcare chaplains who seek to maintain compassionate, patient-centered care while adapting to new documentation standards.
What is Open Notes?
The Open Notes initiative, under the CURES Act, mandates that patients have the right to view their clinical notes. For chaplains, this means that the spiritual care notes we write are now accessible to the patients we serve. While this enhances transparency and encourages a more collaborative approach to care, it also requires additional mindfulness in how notes are written. As a chaplain, our notes may now directly influence a patient's understanding of their healthcare journey.
Best Practices for Charting in Light of Open Notes
Humanize and Empower
Our role as chaplains is to provide emotional and spiritual. With Open Notes, it's essential to use language that humanizes our patients. Highlight their strengths and resilience, even when discussing challenges or struggles. Avoid using language that may come across as judgmental or disrespectful. For example, instead of saying, "the patient was upset," consider using, "the patient reflected on their emotions and shared feelings of frustration." This not only respects the patient's experience but also reinforces their agency in the healing process.
Avoid Phrasing that Implies Doubt
Some phrases commonly used in medical documentation, such as "the patient stated" or "the patient reported," can unintentionally convey skepticism. While these evidentials are standard in medical records, chaplaincy documentation should aim to create a supportive narrative that promotes trust and understanding. Opt for verbs that demonstrate collaboration, like "explored," "reflected," or "discussed." For example, "Together we explored the patient's feelings of anxiety and discussed potential sources of comfort."
Mindfulness and Sensitivity
Before finalizing any note, it's important to pause and reflect on how the patient might feel reading it. Would they feel respected, heard, and supported? Notes should reflect the chaplain’s role in accompaniment—walking alongside patients during their time of need. One way to ensure this is to write brief, focused notes that capture the core themes of your conversation with the patient, while maintaining an overall tone of empathy and care.
Examples of Chaplain Notes
Example of a Good Note
During our visit, the patient shared feelings of sadness and reflected on their concerns about limited family visits. We explored how this has impacted their sense of support during their hospital stay. The patient was tearful at times, and I provided space for them to express their feelings. While they did not wish to discuss faith, we discussed sources of comfort that might be meaningful to them, such as reading or listening to music. We plan to revisit these topics in future visits.
Why it works:
The language is respectful and neutral, avoiding phrases that could imply doubt.
The note highlights both the patient's struggles and their ability to reflect and engage in meaningful conversation.
The chaplain acknowledges the patient's preferences and provides a plan for future care.
Example of a Bad Note
Patient seemed upset and reported feeling hopeless. They said their family doesn’t visit, but I wasn’t sure if that was entirely true. I tried to talk to them about faith, but they didn’t seem interested. The patient cried a lot and didn’t want to engage.
Why it doesn't work:
The tone of skepticism ("wasn't sure if that was entirely true") casts doubt on the patient’s honesty.
The note focuses only on the negative aspects without highlighting any patient strengths or agency.
There is no attempt to explore alternative areas for meaningful support, and the note feels unresolved and dismissive.
Cautions with Open Notes
While Open Notes is a step forward in patient-centered care, it also poses potential challenges. A patient might misinterpret a well-meaning note or feel distressed by language that they perceive as negative. Thus, charting should always be done with caution, particularly when addressing sensitive issues such as emotional distress, end-of-life discussions, or difficult family dynamics.
Another key consideration is the balance between transparency and professional discretion. As chaplains, there may be moments when discussing every detail in the patient record may not be in the patient's best interest. In such cases, it's important to use discretion and consult with the team to decide how to document those interactions while still maintaining a commitment to open and compassionate care.
Conclusion
The integration of Open Notes into healthcare chaplaincy provides an opportunity for more transparent, patient-centered care. It also brings new challenges, requiring chaplains to carefully consider how their words impact patients when those words become part of the patient’s medical record. By remaining thoughtful and intentional about how we chart, we can continue to provide the compassionate, empowering care that lies at the heart of chaplaincy.
