Pastoral Care Documentation: An Aspect of the Care We Provide
By George Hull
Editor, Pastoral Report - The Newsletter of the College of Pastoral Supervision & Psychotherapy
Hospital chaplains face an interesting dynamic when it comes to documenting pastoral care in the patient’s medical record. We can spend an hour sitting with a patient or their loved ones, listening carefully to what is being said and wondering about what remains unspoken, and then feel that the real work is over. What remains is the documentation of the visit, and it can feel more like paperwork than care.
Perhaps, however, we have it backwards.
A pastoral encounter does not simply end when the chaplain leaves the room. Something of that encounter remains: a moment of recognition, the sense of a meaningful conversation, or the lasting impression of having been heard and taken seriously. The pastoral care note provides another way for something of that encounter to remain available to those who continue caring for the patient.
A well-written note helps the next member of the healthcare team learn something about the patient that might otherwise go unnoticed. An attending physician may better understand why a family is struggling with difficult decisions at the end of a patient’s life. Longstanding family tensions or other unfinished business of life may shape how people respond to the impending death of someone they love. A nurse may recognize that a patient who appears calm is, in fact, deeply worried. Another chaplain may understand why a follow-up visit is important. A social worker may become aware of a family conflict that is complicating communication or decisions about the patient’s ongoing care.
In this sense, the pastoral care note is more than a record of what happened during the chaplain’s visit. It is a bridge between one visit and the next.
It also provides the healthcare team with another perspective on the patient’s experience, another piece of the larger picture of who this person is and how they are experiencing their hospitalization.
Four Basic Types of Pastoral Care Visits
There are many reasons a chaplain may enter a patient’s room. Four basic types of pastoral encounters illustrate why documentation matters.
The Initial Visit Establishes Availability
The initial visit is, in many ways, an introduction. The chaplain is saying, in effect, “I am here. You do not have to navigate this experience without support.”
The visit gives the patient and their loved ones an opportunity to learn who the chaplain is, what pastoral care offers, and how to request another visit.
Just as importantly, the conversation may begin to reveal what matters most to the patient: important relationship concerns, matters about hospitalization, sources of support, questions of life’s meaning, or other matters the patient or family wishes to discuss.
The chaplain’s documentation records the beginning of that relationship. It provides other members of the interdisciplinary team with context for understanding the patient’s experience from a pastoral perspective.
The Follow-Up Visit Establishes Continuity
The follow-up visit focuses on continuity of care. The chaplain has already met the patient and returns as a familiar presence.
In the hospital, where physicians, nurses, and other caregivers may change from day to day, the chaplain may be one of the few familiar faces the patient sees throughout the hospitalization. The chaplain places no particular demands on the patient. Sometimes the most important thing about a follow-up visit is simply that the chaplain remembers and shows up.
Documentation helps facilitate that continuity. It allows another chaplain or member of the healthcare team to understand what has changed, what remains important, and why another visit may be helpful.
The Referral Responds to a Particular Need
A referral usually begins with someone noticing that a particular concern warrants attention. A staff member, patient, or family member may request a chaplain because something difficult or significant is happening.
The referral may involve family conflict, questions about meaning, or a change in the patient’s status that affects goals of care.
For example, a patient and their loved ones may request pastoral support as treatment goals shift from curative to comfort-focused goals of care as the patient approaches the end of life.
Documentation helps clarify why the referral was made, what the chaplain encountered, and what may be important for the care team to know going forward.
The End-of-Life Visit Attends to the Patient and Family
At the end of life, the meaning of hospitalization can change profoundly. Medical questions become intertwined with questions about relationships and the unfinished, complicated business of life. The chaplain may be present at a moment when a patient and their loved ones are trying to understand what is happening and how they will get through it.
Sometimes the chaplain’s most important contribution is simply to remain present as a family begins to grasp the reality of what is happening. The chaplain may also provide support before death and bereavement support for family and loved ones after the patient’s death.
In each of these encounters, documentation should help answer a simple question:
What does the next member of the healthcare team need to know to continue providing good care for this patient and their family?
That question changes how we think about documentation.
The Discipline of Stating What We Know
Pastoral care documentation should reflect the chaplain's particular perspective and responsibility in patient care. This involves describing what we observed without attempting to label or diagnose the patient.
During a pastoral visit, a chaplain might observe that a patient seems withdrawn, tearful, or hopeless, or shows little interest in activities they previously enjoyed. While these signs can be significant, they alone do not confirm a diagnosis of depression. The patient could be grieving, frightened, overwhelmed by hospitalization, or worried about the impact on their family or finances.
For example, rather than documenting:
“The patient is depressed.”
the chaplain might document:
“The patient was tearful throughout the visit and expressed feelings of hopelessness.”
We note that this distinction is important. The initial statement presents the chaplain’s diagnostic conclusion, whereas the second details what the chaplain observed during the pastoral visit.
The same principle applies to other clinical terms. If another clinician has already made an assessment, the chaplain can accurately report that assessment and identify its source. Otherwise, the chaplain should describe what the patient said, what the chaplain observed, and what occurred during the pastoral encounter.
This is particularly important when a patient makes a statement that could indicate a risk of self-harm.
For example, a chaplain might document:
Patient stated, “I don’t see any reason to keep going.” When asked what they meant, the patient stated, “I just want to get into my car and drive it into a tree, then it would be over.”
The chaplain is not making a suicide-risk diagnosis. The chaplain is documenting what the patient said and recognizing that the statement may indicate a serious safety concern.
This statement should never be used only for documentation. It indicates important clinical information that must be communicated immediately to the patient’s nurse and other relevant healthcare team members. If in doubt, seek consultation; call the director of the department of pastoral care.
The chaplain’s responsibility is to communicate what took place and understood during the pastoral visit.
This requires asking:
What did the patient actually say?
What did I observe?
What meaning did the patient give to the experience?
What other relevant information should be shared with the healthcare team?.
These questions allow the chaplain to contribute something distinctive to the overall care of the patient and their loved ones without claiming more than the chaplain actually knows.
Documentation as Part of the Care
Perhaps this is why pastoral care documentation deserves to be understood as part of pastoral care itself.
The chaplain enters the room, listens, and encounters something of the patient’s experience. Then the chaplain documents the pastoral visit. That note becomes part of the larger conversation of care.
The physician may read it. The nurse may read it. Another chaplain may read it. A social worker may read it. Each may come to understand something about the patient that might otherwise have gone unnoticed.
The note cannot reproduce the pastoral encounter, nor should it try. Its purpose is to preserve what is relevant and important for the patient’s continuing care.
Good documentation states, in effect:
This is what I encountered.
This is what the patient or family expressed.
This is what seemed important.
This is something the team may need to carry forward.
The chaplain’s work is often about creating a space where patients and families can say what matters when life has become frightening or uncertain. Documentation allows a small part of that pastoral encounter to become part of the larger sphere of patient care.
Seen this way, documentation is not simply what we do after the pastoral visit.
Most importantly, it is one way we continue to care for the patient after we have left the room, and that’s the bottom line.
