Abstract:

“If it is not charted: it did not happen.” The charting of healthcare chaplaincy contacts in patient files has been controversially discussed in the literature in recent years. In particular, entries in digital medical records raise questions among pastoral care managers about confidentiality, data protection regulations and managerial interests.

The European White Paper on charting in healtcare chaplaincy argues that charting chaplaincy contacts with patients and relatives (1) makes their spiritual needs visible, (2) contributes to improved interprofessional communication about chaplaincy and (3) makes the work of chaplains transparant. Charting improves the quality of care for patients, promotes the professionalism of chaplaincy and facilitates interdisciplinary exchange and multi-professional cooperation. It should be noted that entries in patient files should be made as if the patient were reading them. Descriptions must be adequate, understandable and concrete: The reason for the contact, assessment, changes resulting from the contact, interventions made and further planning are five steps of patient-centred pastoral care documentation. They respect patient rights and the principles of clinical ethics. In each case, questions of the software used, access rights and the use of the collected data material need to be clarified.

The documentation of chaplaincy contacts can improve the relationship between patient and chaplain if it is included in the care. Last but not least, chaplaincy charting creates a data basis for practice-oriented research and training and for the development of the profession.

Author: Anne Vandenhoeck, Joost Verhoef, Daniel Nuzum, Pascal Mösli, David Neuhold, Simon Peng-Keller, Traugott Roser, Linda Ross, Wim Smeets, Austyn Snowden, Wilfred McSherry