www.hospitalchaplain.com- Article Hosted on this site
author- Dr. Simon Harrison
date- March 2001 first published- here
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This article has been put on line to allow feedback from other chaplains on how they feel about the chaplaincy relationship with patient documentation. It is Mental Health orientated but need not necessarily be restricted to this area.
DRAFT- The appropriate use of notes when providing for the religious, spiritual and pastoral care of patients in a psychiatric setting.
General issues of confidentiality
There are to date no specific guidelines regarding confidentiality covering Chaplains, except to restate that as a member of the hospital staff, our duty is to that organization before any other body (e.g. the church).Therefore it is accepted that Chaplains do not have any obligation (or right) to share confidential information received through their role as a Chaplain with any third parties. This places their duty to confidentiality on a par with all other staff employed by the Trust.
Reading and contributing to patient notes
With regard to the confidentiality of information recorded in patient notes, the Chaplain is effectively in the same situation as any other member of the team. Confusion can sometimes arise among staff as to whether the chaplain is considered part of the ancillary staff (eg domestic/catering) or a member of the multi-disciplinary team. Such confusion should be handled sensitively and not be reacted to in a negative manner. Nurses are often in a position where others seek to gain access to notes without appropriate reason or rights of access, for example, with the police and patient solicitors.
This said, in the circumstances when a chaplain makes use of the notes or documents their own intervention, it seems relatively obvious that the Chaplain is one element of the integrated care team. For example, a chaplain may be involved in contributing to the spiritual or pastoral element of the care plan, and should at the least be seeking to work within it. Indeed, one could suggest that it is futile to have a care plan at all if one of the staff team working closely with a patient does not have access to it. This is particularly true when Trust documentation has been developed to involve such elements as a ‘spiritual needs assessment form’ to be completed by the chaplain, or where the hospital has a policy of documenting any significant intervention by chaplains. An example of such intervention which merited documentation may be the giving of a bible to a patient often suffering from delusional belief formations This would clearly be discussed with staff on duty, but would also merit documentation in case it were a significant factor in the patients well-being (for good or ill).
In some UK institutions (forensic, secure & general) it is clearly expected that the Chaplain will attend all ward rounds, and also case conferences when they have been doing particularly intensive work with a patient. In these situations, a working knowledge of the notes is likely to be valuable and probably will be inevitable.
The frequency of use of nursing and medical notes by chaplains
This said, working with most patients may not need this level of intimacy with notes, and it can also sometimes be beneficial in the Chaplain’s role to work without presumptions, when the role is simply that of an independent listener. Most Chaplains do not make regular use of nursing notes for this reason, relying on good communication from other members of the multi disciplinary team for guidance of the patients well-being and state of mind.
With regard to the medical notes, they are not of great relevance to pastoral and spiritual care work in many cases, although there are occasions when it is valuable for a Chaplain to access these. This is most likely in rare situations when a Chaplain is working very closely with a patient, and is dealing with issues that require a) more particular insight than is directly available from the patient and b) when it is inappropriate to ask nursing staff for the information. Here the situation may be that the patient has discussed something which could be of considerable significance to the work (or constitute a risk to others) but the chaplain is unclear of either the significance of the risk without further evidence. This means that there may be insufficient justification for disclosing to other staff at this stage. Examination of notes in such cases is one way in which the judgment of the Chaplain may be improved without immediate recourse to breaching of confidentiality.
Chaplaincy duties of confidentiality
This rare justification for use of medical rests on the presumption that Chaplains work to a tighter confidentiality policy than other disciplines, seeking to maintain the patient confidentiality even when it may be in their best interest to disclose to the wider team. The possibility of such situations is a reminder to all chaplains that the boundaries of confidentiality need to be explained to a patient before a patient seeks to disclose information based on a false belief that such information can never be shared. Although it can seem unnatural, it is good practice to advise all patients that information which they disclose to you which constitutes a threat or the possibility of harm to themselves or others cannot be kept from the wider team. With such an agreement in place, it is then possible for the chaplain to re-iterate the confidentiality of other information, or seek permission from the patient to share appropriate information with other staff when the need arises. Of course, such confidentiality regarding information does not (and should not) preclude Chaplaincy staff from sharing insight or professional opinion within the wider team, although such sharing should not be used as way of circumventing confidentiality by ‘hinting’ at matters the patient has disclosed in confidence.
Procedures when accessing medical notes
Clearly, if one was working with a patient to such a degree that medical notes are helpful, both nursing and medical staff need to be made aware of this, and it may be good practice for it to be noted in the nursing notes when a Chaplain has requested to see the medical notes- highlighting the level of involvement. Making such access to notes dependent on disclosing the reason for needing them would probably undermine any reason for consulting them on the rare occasions when medical notes might be relevant. It is better that such access is available on the same need-to-know basis as with others in the team, and any conflict over such use would result in the use being justified on an individual basis, normally with the patients consultant.
To summarize:
Although Chaplains often depend mainly on verbal communication within the team, and seek to maintain a stricter degree of patient confidentiality it can sometimes be appropriate as a member of the team to make direct use of patient documentation, whether this be regarding nursing notes, specially developed spiritual care documentation, nursing care plans, (reading or contributing to), and in rare cases the medical notes.
Simon Harrison
Langdon Hospital (Forensic Psychiatry Services )
03/01
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