Monday 24 August 2009

Note Keeping

Because of audits and keeping track of who is where with whom chaplains have to keep some notes. It’s worth remembering the intent of these notes, what they’re not intended for and how they may be used.

The written word has such enormous authority and at the same time can be so ambiguous as to be used and misused by people with very varying purposes.
There’s an art to note keeping, you need to record the fact that you and a particular patient met at a certain date and time and that’s it. There’s a temptation to go into detail and things can begin to unravel quickly, sometimes years after the event.

“X seemed excited today” can be read as “X was sexually aroused.” “X was agitated:” was that generally or specifically around you? Did that agitation have any connection to his behaviour later in the evening, and who did you inform about his agitation? If X goes on to offend or if a clinician or a barrister wants to make a point about X or about your relationship with X or with your way of practicing you can see how your own words can be used to prove something that you did not intend. If we use words that we don’t really know the full meaning of – like ‘manic’ or ‘depressed’ or ‘labile’ – then those words can come back to bite us, used both to prove something about a patient or to demonstrate our own lack of knowledge. You can imagine in a court being asked: “Can you describe what you understand the meaning of ‘manic’ to be? And can you tell the court what your professional qualifications are?”

I get a bit weary when overly anxious people start making noises about the desperate threat of litigation and how we must protect ourselves by messing everyone else about. Personally, as long as the patient, the ward staff and I are happy for something to happen, like taking a patient off the ward, then off we go. It would be so much more safe if we remained in a glass box with audio and videotaping but there are implications for the quality of our relationship. But. The written word supersedes memory in importance. Notes are, not unreasonably, assumed to be an accurate, contemporaneous record of events.

I write notes as if the patient is going to read them which helps me stay focused on what I’m communicating and how it may be read. It’s easy to forget that whilst we are afforded the same respect as other professionals in a clinical setting we are not serving the hospital but the patient. It’s tempting to try and match specialist language or to demonstrate to a putative professional reader that we function at the same level as they do; a paradoxical temptation since the less confident and settled we feel in the role of chaplain the more likely we may be to fall into this style of writing. In the very unlikely event that you’re asked to write anything more than the fact you met then you really should ask for written guidelines about how to write notes for that hospital, then discuss them in depth with the lead chaplain and write those notes under their guidance at the same time as keeping your highest ideal very clear in your own mind.

Perhaps the most fragile and important aspect of the relationship between chaplain and patient is trust and every attempt must be made not to break it. Patient confidentiality should be the basis from which anything is written. If you have a doubt about their safety or the safety of people around them, your notes are not the place to record this in the first instance, you should seek immediate and appropriate support, almost certainly from the lead chaplain. Before you discuss a patient with anyone else it’s an article of faith that you discuss it first with the patient themselves. Saying “I’d like to talk to my boss about this,” creates a space for meaningful communication, you’re demonstrating that you know your limitations, that you’re confident in discussing your limitations with the patient – because it’s not a matter of weakness to know when things are going beyond your remit, quite the opposite. And it models the normality and safety of knowing that we can’t deal with everything on our own, that discussing a difficult matter with someone trustworthy is worthwhile.

When you’ve talked with the lead chaplain and come to a decision, put that in the notes. A patient told me he was going to try to abscond. We talked about why and what this might achieve and so on and still, he declared he was going to try to escape. I didn’t actually believe that this was the case at all, but an expression of despair, a desire for boundaries and attention which would be achieved when I told the staff, which I was obliged to do. But first I told the patient that this was the case (as he knew it was) and that I would have to talk to my boss. I made a verbal contract with the patient that they would not abscond and not make a final decision about absconding until I’d spoken with my boss. Then I asked for an urgent meeting with my boss which primarily served to help me feel better about talking to the ward staff, 15 minutes later. My notes remained very short, about 2 sentences more than normal and limited to absolute fact. Life in hospitals is dramatic and gossipy enough: there’s no need to add to it or get caught up in it.

Confidentiality is entirely breached if you are summonsed by a court, which may happen if your patient does something unlawful or accuses the hospital of something unlawful. In my private psychotherapy practice I simply don’t keep client notes any more which simplifies matters no end and I shred my personal reflections, which are about me rather than clients, around a year after we finish meeting. But hospitals keep notes for a minimum of 5 years and particularly in psychiatric care they can be kept a lot longer and have the potential to be incendiary.

Some of the patients I see are likely to reoffend when they leave hospital and it’s possible that some years into the future I may be asked to give evidence in court. What are my responsibilities? Who am I serving? My answer is that I am serving the cause of truth, that I am not a judge or a jury and that justice will be served by them, not me. The relationships that are co-created with the people I see are delicate, part of the healing process is served by offering and being able to sustain deep trust. If they are then accused of something grave I have to just answer questions as faithfully as I can and put a great deal of trust in the Goddess. I fervently hope it never happens.

Note keeping is a vague subject at the best of times and there are differences between US and UK practice. In the US the Health Insurance and Portability Act appears to cover this minefield. (In an avalanche of impenitrable information, Wikipedia seems to have the best coverage. But my keyboard doesn't have a hash key and the link requires it.)

Here is something less fuzzy for US chaplains that is also of interest to UK chaplains.

Frankly, I have little idea what the Data Protection Act has to say on the matter but believe in keeping it really simple: I keep no chaplaincy notes on my own computer. I used to send my notes by email, but now write them at home, print them out, hand them over to the Chaplaincy Office at my next visit, and keep one copy in a file in a locked filing cabinet. If I know my next visit is going to be longer than a week I’ll write the notes at the end of the day in the hospital itself and take them to the office.

Wherever you practice your chaplaincy notes should be kept separate from the clinical notes. Although spirituality has a proven positive contribution to wellbeing and health, chaplains are not part of the clinical team for excellent reasons. We are not primarily concerned about cure or illness or insurance, it’s not our role to be involved in diagnosis or medication or anything other than the wellbeing of that persons essential being that exists beyond their body or their mind. It’s impossible to capture that relationship on paper and so lets not attempt to. Keep it simple: 'Met with X. Spirituality discussed'

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