Communicating Spiritual Care in the Electronic Health Record

Chaplains must document their ministry of care in electronic health records that primarily focus on the physical dimension of care. Creating chaplain documentation that reflects the spiritual dimension of care requires chaplains to participate in the screen design. This article describes how chaplain documentation was designed and refined using psychometric methods. The resulting system successfully supported chaplain workflow, provided an ability to aggregate chaplain workload, and integrated the chaplain into the interprofessional team by structuring, linking, and sharing both the chaplain and nursing assessment of spiritual distress in the electronic health record. Documentation used 5-point Likert scales to measure different dimensions of patient spirituality. Reliability and validity were further evaluated as part of a workshop at an Association of Professional Chaplains annual meeting. Findings supported interrater reliability and the ability to predict and discriminate change pre and post encounter. Documentation screen content is presented.