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8/6/2018 Evaluating Chaplain Chart Notes Webinar Three in a Four part Series July-August, 2018 Gordon J. Hilsman, D. Min. 3 o1 3 Copywrite


  1. 8/6/2018 Evaluating Chaplain Chart Notes Webinar Three in a Four part Series July-August, 2018 Gordon J. Hilsman, D. Min. 3 �������������������� �����������  o1 3 Copywrite Gordon J Hilsman ghilsman@gmail.com 1

  2. Slide 3 o1 owner, 4/10/2007

  3. 8/6/2018  ����������������������������������� ����������������������������������� ��������������������������� �������������������������������������� �������������� ���������������� �����!���� ����0��������- 1������2�������������   ������ ����3������������������������&������ ��������*������� ��� 4��������4�5 ����� 4��������������&�  ������� ���4���������������������������������������� ������������6������7��������4������8���� ���������� &��9� ��� 4��������������4�5 ������� 4�������������+����)�����/� ���������4�4����������������������������������&�  ��������" #������������������$���������%������������� &'������������(����)�����*�+���,,-�,"./���������&�������*�� �������������������������������������������������  )�����������������������: +;������������������������������������������� ������������������������������<���/� Copywrite Gordon J Hilsman ghilsman@gmail.com 2

  4. 8/6/2018 ������������������ #�������������������������������������-   '����� ��������������� ���������������������������=  ��������� ���������������� ��������������  ������������������������������������������������  >�������������������� �����������������������  ���������� ��������� ������������������������?���� ���������  0���������� �������������� ���������������������������� )�������������������   �3�������������  �����7������+����������������/  @��������������������<����������3�����  A������������"�3��������  )���������������"���������  0������������������  )�����������������������  �����!�������������������������B����� Spiritual care notes are: � Human to Human (Intersubjective and direct) � Earthy (vs. tidy, neat, proper, correct) � Stark, Striking, Interesting, colorful, punchy, pithy � Quote Illustrated (for concreteness) � Intuitive (blended with good sense) � Concise � Mostly devoid of self reference Copywrite Gordon J Hilsman ghilsman@gmail.com 3

  5. 8/6/2018 Chart Evaluation Exercise Example # 1: 27 y/o, second language � RoseMary daughter mid-50s appeared anxious, hopeful and was in tears right before her father’s procedure. She requested prayer before he went in, after the prayer was said it seemed to bring her and her father comfort while waiting for the procedure to be over she was notified that her father coded. We walked down together and received the news that they were working. She was distraught to receive the news and in tears weeping loudly her sister was notified via phone and her brother was shortly notified as well. Her father was taken to MICU where her family arrived. She expressed great faith in “God and in his plan, and his will.” Example 1#: Bullet Points � Daughter says she was looking forward to celebrating his 80 th birthday next month � The chaplain extended the ministry of his presence and support to RoseMary, by listening compassionately and waiting ‘till the family arrived � The daughter expressed appreciation for the chaplain’s visit Copywrite Gordon J Hilsman ghilsman@gmail.com 4

  6. 8/6/2018 Consultative Comments � The note is functional. It works. Perfect English is not to be pursued with any vigor. � Learning to be concise in charting takes effort, time and persistence. � The note might have made it explicit that the daughter was aware that her father could die after the surgery. (Which he did.) � Arenas here – Losses and “Childing”— give rise to spiritual needs of immanent grief and fear. They are clearly implied but not made explicit. 1. Need To Talk Axis 1: EMOTIONAL SUPPORT NEEDS Spiritual 2. Minimizing Fears and Anxiety Needs 3. Assuaging Resentment and Hostility 4. Healing Sadness, Discouragement, Despair Framework A 5. Addressing Deep Hurt 6. Empowerment 7. Current or Recent Loss S 8. Prior Loss Axis 2: MAJOR LOSS S 9. Dying NEEDS Establishing Rapport 10. Life Adjustment E 1. Careful Listening 11. Estrangement 2. Empathic Reflecting 12. Religious Support S 13. Spiritual Validation 3. Gentle Query Axis 3: RELIGIOUS/SPIRITUAL S 14. Spiritual Counseling 4. Supportive SUPPORT NEEDS 15. Self-Forgiveness Validating I 16. Instructing 5. Insightful N Interpreting 17. Ethics Confusion 18. Addiction/Mental Illness Concerns G 19. Advocacy Axis 4: REFERRAL NEEDS 20. Family Conflict 21. Love Life Pain Example #2, a 32 y/o Catholic Seminarian, former military, experienced med. Tech. � Patient is a 48 y/o male experiencing abdominal pain. Presents as very alert, polite, and devout member of his own faith, with a great respect for individuals and members of other spiritual traditions. Patient vocalized having a strong family, and garners a strong sense of purpose in his religious devotion. Healthy spiritual state, and no follow-up planned at this time. Copywrite Gordon J Hilsman ghilsman@gmail.com 5

  7. 8/6/2018 Consultative Comments � Reassuring note about a positive attitude towards treatment and hospitalization. � Seems rather superficially positive. No spiritual needs identified. Maybe so! � Bullet points? Presenting the Note Orally � It helps if the charting person presents the note orally when possible. That brings to the surface elements left out, by neglect or ethical protocol. For example the following patient had three small children, a new helpful boyfriend after extricating herself from the abusive father of her children; a history of abuse by her father; one of her children had recently been “touched” at school which was reported to state social services; and she had gone to a priest for help who leaked confidential material to the woman’s sister. Some but not all of that could be communicated to the nursing staff and physician. Example #3: 60 y/o first unit student, married spiritual director, Ms. F is a 28 y/o mother, trying to wait for a few more weeks in the hospital for the health of her unborn baby. She is having a hard time not being at home with her children. Ms. F also has other medical problems, which has complicated her health with the baby. � The patient spoke about her children, and her relationship with her parents and siblings. It is a hard situation. She talked for about 90 minutes. � Ms. F. spoke of faith and her relationship with God. She said she was a lonely person. She said she did talk with God. He was the only one she could talk to. � I prayed with her and gave my card with my pager number. I told her I’d come back to visit with her and I or anyone in the Chaplain’s office would come if she requested us. She though she’d be in the hospital for another 3 weeks. Copywrite Gordon J Hilsman ghilsman@gmail.com 6

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