Patient Assessment: What to include?

As chaplains, ethicists, pastoral and spiritual care providers we have the obligation the ensure that we are responding to the patient’s real needs and not needs we have identified ad hoc for the patient, whether that person is in chronic, long-term care, acute care, or in paliative or end-of-life care.

spiritual_assessment_individual

It is extremely important that providers in each of the disciplines providing care based on a holistic, multidisciplinary model be aware of the cultural, ethnic, spiritual beliefs and values, and the expectations and desires of the person receiving healthcare services.

At all times we must separate ourselves from our own belief and value systems, a process that is not without its overheads, and concentrate on the person before us, recognizing his or her autonomy, dignity, and self-determination, and not losing sight of our potential roles in violating those ethical principles of the person.

We must also bear in mind the personal, professional, and instituional  boundaries, both rigid and flexible boundaries, that constrain our behavior and conduct.

We must train ourselves to be active listeners, providers of a ministry of intentional presence, empathetic and compassionate, and at all times humble.

We must also be acutely aware of the potential for transference and countertransference to occur in the therapeutic alliances we forge with our patients and their families.

I am personally convinced that a thorough biopsychosocial and spiritual assessment procedure helps considerably in our work. To that end, I have done extensive research to finally consolidate my findings into what I call an Intake Template for use bythe  professional chaplain or spiritual/pastoral care provider in the clinical setting.

The Intake Template is rather long but is not intended to be administered all at once, though it could be and to do so would require about 45 minutes to 1 hour, depending on the situation. Some information should be elicited in one session, face-to-face, other information, such as the scoring forms, can be left with the patient and later collected, discussed with the patient, and analyzed and discussed in the care planning meeting.

I am providing a downloadable pdf of the Intake Template and would ask my readers and colleagues to download the template and, at your convenience, to review it and comment on it. That would be very helpful in tweaking the template so that it can find broader application and use.

spiritual assessment toolClick here to view/download the Intake Template.

Althought the Template claims copyright protection, I hereby grant permission to you to use the template as a professional chaplain/care provider in your professional environment.

Thank you in advance for your collaboration and support,

Ch. Harold W. Vadney
pastoral.care.harold@gmail.com

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