Findings on Medical Records Reported by Investigators at Duke University Hospital (Documenting presence: A descriptive study of chaplain notes in the intensive care unit)
By a News Reporter-Staff News Editor at Health & Medicine Week Investigators publish new report on Medical Records. According to news reporting originating in Durham, North Carolina, by NewsRx journalists, research stated, "To clarify and record their role in the care of patients, hospital chaplains are increasingly called on to document their work in the medical record. Chaplains' documentation, however, varies widely, even within single institutions."
The news reporters obtained a quote from the research from Duke University Hospital, "Little has been known, however, about the forms that documentation takes in different settings or about how clinicians interpret chaplain documentation. This study aims to examine how chaplains record their encounters in an intensive care unit (ICU). We performed a retrospective chart review of the chaplain notes filed on patients in the adult ICUs at a major academic medical center over a six-month period. We used an iterative process of qualitative textual analysis to code and analyze chaplains' free-text entries for emergent themes. Four primary themes emerged from chaplain documentation. First, chaplains frequently used code language, such as compassionate presence, to recapitulate interventions already documented elsewhere in a checklist of ministry interventions. Second, chaplains typically described what they observed rather than interpreting its clinical significance. Third, chaplains indicated passive follow-up plans, waiting for patients or family members to request further interaction. Fourth, chaplains sometimes provided insights into particular relationship dynamics. Significance of results: As members of the patient care team, chaplains access the medical record to communicate clinically relevant information. The present study suggests that recent emphasis on evidence-based practice may be leading chaplains, at least in the medical center we studied, to use a reduced, mechanical language insufficient for illuminating patients' individual stories."
According to the news reporters, the research concluded: "We hope that our study will promote further consideration of how chaplain documentation can enhance patient care and convey the unique value that chaplains add to the clinical team."
For more information on this research see: Documenting presence: A descriptive study of chaplain notes in the intensive care unit. Palliative & Supportive Care, 2017;15(2):190-196. Palliative & Supportive Care can be contacted at: Cambridge Univ Press, 32 Avenue Of The Americas, New York, NY 10013-2473, USA. (Cambridge University Press - www.cambridge.org; Palliative & Supportive Care - journals.cambridge.org/action/displayJournal?jid=PAX)
Our news correspondents report that additional information may be obtained by contacting P.J. Choi, Duke Univ Hosp, Div Pulm & Crit Care Med, Durham, NC, United States. Additional authors for this research include F.A. Curlin and B.M. Lee (see also Medical Records).
Keywords for this news article include: Durham, North Carolina, United States, North and Central America, Records as Topic, Medical Records, Hospital, Duke University Hospital.
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